Pharm Exam #3

Non-Contraceptive Use: Progestin

► Individual variation: • *Undiagnosed abnormal vaginal bleeding* • History or active thromboembolic disease, cardiovascular disease, and history of breast cancers • Pregnancy (esp. in first 4 months) ► Nursing Implications: • Assessment/monitoring: breast exam, pregnancy test, s/s of VTE, vaginal bleeding ► Patient education: • Take with food to reduce GI upset • Report abnormal bleeding, and s/s VTE

5-alpha reductase inhibitors

► Individual variation: *do NOT* use in pregnancy (Category X) ► Nursing Implications: • Assessment/monitoring: • Symptoms resolution will take at least 6 months or longer • Administration: *use hazardous drug precautions when handling* - teratogenic • Patient Education: • Pregnant individuals or those planning to become pregnant should not handle crushed or broke medication • Patient cannot donate blood unless medication has been discontinued for at least 1 month (bc pregnant person might receive blood)

Tuberculosis

► Infection caused by Mycobacterium tuberculosis (slow-growing so need long treatment) ► Transmitted from person to person by coughing or sneezing - Inhalation of infected sputum ► Can be limited to lungs or may become disseminated to other body parts including kidney, spine, and brain

Which instructions will the nurse include when teaching a patient about cephalexin? Select all that apply a) "Notify your healthcare provider if you develop diarrhea." b) "You can stop the medication when your fever is gone." c) "Notify your healthcare provider if you develop a rash." d) "Cephalosporins may not be taken with food." e) "You cannot drink alcohol when you are taking this medication."

a, c

A patient with a history of a severe anaphylactic reaction to penicillin has an order to receive cephalosporin. What should the nurse do? a) Administer the cephalosporin as ordered b) Contact the healthcare provider to request a different antibiotic c) Administer a test dose of cephalosporin to determine reactivity d) Have an epinephrine dose available when administering the cephalosporin

b -potential for cross-sensitivity bc severe reaction

A patient contacts a clinic nurse to determine the proper action after she forgot to take her oral contraceptive [Ortho Tri-Cyclen] for the past 2 days during the first week of a 28-day regimen. Which response by the nurse is most appropriate? A. "Take the omitted 2 doses together with the next dose." B. "Take two doses per day on the following 2 days." C. "Stop taking the oral contraceptive until menstruation occurs." D. "Take a dose now and continue with the scheduled doses."

b she was bitchy in this response, i don't think this will be on exam

► Which of the following supplements should the nurse administer to patient HP to prevent an adverse effect of isoniazid? A. Ascorbic acid B. Pyridoxine C. Folic acid D. Cyanocobalamin

b vitamin b6, for peripheral neuropathy

A patient has been prescribed sildenafil [Viagra] for erectile dysfunction. Which instruction should the nurse include in the teaching plan? A. Take the medication on an empty stomach B. Drink plenty of fluids to prevent priapism C. Avoid taking nitroglycerin with this drug D. Constipation is a common adverse effect

c

Which patient would be at greatest risk of developing a venous thromboembolism (VTE) if a combination oral contraceptive were prescribed? A. A 25-year-old patient who drinks 3 to 4 alcoholic drinks a day B. A 45-year-old patient who has a family history of gall bladder surgery C. A 22-year-old patient who smokes 2 packs of cigarettes a day D. A 29-year-old patient who has used birth control pills for 9 years

c

► Patient HP's home medications include amlodipine, warfarin, carvedilol, and multivitamins. Which of these medications requires lab monitoring due to its interaction with rifampin? A. Carvedilol B. Amlodipine C. Warfarin D. Multivitamins

c

► Which labs should patient HP's nurse monitor for his RIPE therapy? A. Vitamin D levels B. Potassium levels C. Liver function tests D. White blood cells

c -hepatotoxicity

A prescriber states that a patient will need to receive penicillin intravenously. The nurse anticipates administering which drug? a) Penicillin VK b) Penicillin G procaine c) Penicillin G benzathine d) Penicillin G potassium

d

► After a month of taking his RIPE therapy, patient HP complains of blurry vision. Which of the following medications could cause this issue? A. Rifampin B. Isoniazid C. Pyrazinamide D. Ethambutol

d

Your patient is prescribed a transdermal testosterone gel [AndroGel]. It is most appropriate for the nurse to teach the patient to do what? A. Apply the gel to the genital area every morning B. Leave the patch in contact with the skin for 24 hours C. Avoid showering or swimming after gel application D. Keep the treated area covered with clothing

d -not c bc no time frame, just have to 6 hours

A patient is taking finasteride [Proscar] for benign prostatic hyperplasia (BPH). The nurse should review which of the following with the patient? A. The prostate gland should increase in size B. Nitrates should be avoided due to dangerous blood pressure lowering effects C. The patient cannot drink grapefruit juice when on this medication D. The patient may not donate blood while taking this medication

d -prostate should decrease in size not increase

Penicillin Allergy Management

► Investigate allergy! what was the reaction? (ex. upset stomach/NVD is not an allergy), when did it occur?, how treated?, etc. help determine if IgE mediated reaction (true allergy) ► Options: • Use alternative antibiotic: cephalosporin (not if anaphylaxis), vancomycin, clindamycin, erythromycin • Skin tests can be employed to test for presence of IgE-mediated allergy • Desensitization but this is risky so only if necessary (i.e., life threatening infection); give small dose and increase exposure over time, can take a long time and risky

You are working as a nurse in the intensive care unit (ICU). Your patient is a 45‐year‐old man who was being treated with several antibiotics and developed a C. difficile infection. The provider has prescribed vancomycin. The family has the following questions: 1) Why is vancomycin being used to treat this infection? 2) What are AEs are associated with vancomycin?

-affects gram positive bacterial infection, used for C diff (oral); when used orally, doesn't get absorbed (stays in GI tract so gets high conc) *vanco (oral) and metronidazole both considered DOC for C diff! - AEs: just GI issues (NVD) since oral just stays in the gut and doesn't get absorbed into blood!

Types

-antibacterial -antiviral -antifungal -antiprotozoal -antihelmintic

As a new nurse you are concerned with the emergence of resistance to antibiotics in antimicrobial therapy. You decide to attend a continuing education seminar on the topic. You learn answers to the following questions: 1) Why does antibiotic resistance occur? 2) What can be done to prevent resistance?

-antibiotics not selective, kill off good bacteria and bad bacteria keep growing -mutate and get stronger -prevent resistance: don't use prophylactic antibiotics; don't use broad spectrum antibiotics if possible; use broad spectrum antibiotics (treat many diff organisms) then tailor therapy once we get C&S; provide 2+ antibiotics (ex. for TB, HIV); complete entire prescribed course; hand hygiene, prevent patient-patient transmission

Matching

-binds divalent cations: tetracycline, + 1 more? -phototoxicity: cipro, tetracyclines -qt prolongation: erythromicin, cipro -allergy: penicillin, sulfa, imipenem -seizures: p

You are working as a nurse in the family medicine office. Your patient is a 65‐year‐old female who was diagnosed with a bacterial pneumonia. The provider has prescribed ciprofloxacin 750 mg twice a day for 10 days. You will be explaining this medication to the patient. You plan to cover the following questions. 1) What is ciprofloxacin? 2) How should the patient take this medication? 3) What other information is important to share about this medication?

-cipro: antibiotic to treat lower respiratory infections, treats the bugs pneumonia usually caused by (don't tell them it's a broad spectrum and we don't know the exact bug); if you're not feeling better in a couple days, come back to the clinic; monitor for AEs; always complete prescribed course of therapy!

Antimicrobial Resistance

-drug making conditions favorable for overgrowth of microbes that have required the mechanisms for resistance (but doesn't cause genetic changes); worse for broad-spectrum antibiotics bc kills off lots of diff bacteria • Use of antimicrobials promotes the emergence of drug-resistant organisms • All antibiotics promote resistance (broad spectrum >>> narrow spectrum) • Amount of antibiotic use • Health-care associated infections (HAI) • Superinfection

Active TB Treatment

-induction phase: RIPE therapy (2 months) -> continuation phase: rifampin + isoniazid (4 months)

You have been assigned to care for Mr. E, a 60‐year‐old with a blood stream infection (BSI). He is on gentamicin therapy intravenous (IV) once daily. You are developing a care plan for him.Your clinical instructor has asked you to answer the following questions and to incorporate the answers into Mr. E's plan of care. 1) How is the gentamicin dosage determined? (You need to know this because you need to assess whether the dose is appropriate) 2) What risks are associated with gentamicin? 3) How is this medication monitored?

-inital dosing based on weight (for gentimicin and IV vanco) and renal function *gentimicin and vanco completely different drug groups (ex. no vanco infusion reaction in gentimicin) -follow up dosing always get levels (trough or peaks and troughs) -small dose, q8 or big dose, extended interval (don't give big dose, extended interval to someone w renal function) -gentamicin one of the top reasons for kidney dysfunction in the hospital -risks: ototoxicity, nephrotoxicity, muscle weakness/paralysis -monitoring: monitor drug levels, always right before next dose; around 3rd dose, get trough; if doing q8, get peak as well (don't get peak if doing extended interval) -get drug level at right time and document exact time you're getting level and exact time the med is being given! -pull trough 5 min before dose (maybe 10-15 before, but should be right before) -get peak 30 min after 30 min infusion (1 hr after start) -get levels again if showing signs of nephro/ototoxicity, or other labs showing signs of toxicity; also get levels if change dose (get levels after 3rd dose of new dosing) -for immunoglycosides, also monitor s/s toxicity, monitor kidney function continuously (BUN, Cr, urine output daily), hearing, DDIs (muscle relaxers/NM blockers, Lasix bc ototoxicity/renal function, any drug that causes renal tox)

Penicillins (name recognition = -cillin)

-oldest and most widely used ► Prototype: Penicillin G (parenteral - IV/IM); Penicillin VK (PO) ► MOA: Binds to penicillin binding proteins; inhibiting cell wall synthesis and causing cell wall lysis ► Therapeutic Uses: Susceptible *bacterial* infections (treatment and prophylaxis), examples: • Strep throat (S. pyogenes) • Endocarditis (S. viridans) • Rheumatic fever • *DOC*: Syphilis (T. Pallidum) -treatment or prophylaxis (ex. neonate exposed from mother) ► Dosage Forms: ► Oral (PenVK) ► IV/IM aqueous form • PenG sodium • PenG potassium ► IM depot [long-acting] • PenG Benzathine • PenG Procaine • **NEVER IV** - not water soluble, can cause clotting

Treating infections is different?

-other drugs usually interact w a receptor, but that's not what we do when treating an infection (effects on organism not patient) • Selective Toxicity - Ability to kill or suppress antimicrobial pathogens without causing injury to the host - Property that makes antibiotics valuable - Difference in cellular chemistry of mammals v. microbes (ex. target cell wall, inhibit enzymes only found in bacteria, etc.) -if see adverse effects, it's bc there's a similar function in humans that the drug is targeting in the organism

Summary Table

1. Rifampin -DDI: CYP inducer -IV: pts on antiretroviral agents, liver disease, alcohol use -AEs: discoloration of body fluids 2. Isoniazid -DDI: CYP inhibitor -IV: hepatitis, liver disease -AEs: peripheral neuropathy - *pyridoxine* 3. Pyraxinamide -DDI: enhanced hepatotoxicity with rifampin -IV: acute gout, liver disease -AEs: hyperuricemia 4. Ethambutol -DDI: aluminum containing antacids -IV: pts unable to report vision changes -AEs: optic neuritis (*E*ye) ***similarities (all): hepatotoxicity (monitor liver fxn), avoid alcohol, education + assistance w adherence

A 45‐year‐old male patient who is experiencing homelessness. He comes to the emergency department with weight loss, lethargy, a low‐grade fever, and a productive cough streaked with blood. His chest x‐ray indicates a suspicious area in the middle right lobe. He is hospitalized with suspected tuberculosis andsputum cultures are ordered (later reveal mycoplasma tuberculosis.)

1. What is the typical initial drug regimen you expect to be ordered for active TB? -RIPE: refampin, idaniazide, purzinimide, ephamiatol (?); use all 4 first 2 months then only R and I 2. What organ function is affected by these drugs? How will you monitor for organ function problems, as well as educate patients to recognize this? -liver function!!! monitor: jaundice, liver enzyme tests (baseline and serial while on this therapy; 3/4 drugs affect liver function) - ALT/AST, bili, etc. 3. What are the benefits of directly observed therapy (DOT)? -watch patient take med, shown to be as effective as watching it in person 4. The public health nurse is evaluating the patient during DOT. The patient reports tunnel vision - what is your concern? What should the nurse do for this patient? -ethambiatol causes optic neuritis!

Transgender Health: Nursing Care Guidelines

Gender Affirming Hormone Treatment • FTM: Increase testosterone levels to the typical male physiological range by administering *testosterone*. • MTF: Decrease testosterone levels to the typical female range by administering an *antiandrogen* and *estrogen*.

Which statement about allergic reactions to penicillin does the nurse identify as TRUE? a) Anaphylactic reactions occur more frequently with penicillins than with any other drug b) Allergy to penicillin always increases over time c) Diphenhydramine is the drug of choice for anaphylaxis from penicillin d) Patients allergic to penicillin are also allergic to vancomycin

a

► After a few days of RIPE therapy, patient HP notices some orange discoloration in his urine. Which of the following medications causes orange-red discoloration of body fluids? A. Rifampin B. Isoniazid C. Pyrazinamide D. Ethambutol

a

Prophylaxis

• 30 - 50% of US use is for prophylaxis; most of that is not necessary • When appropriate? - Surgery (1 dose to prevent common surgery-related infections) - Bacterial endocarditis (less likely to be prescribed today based on new guidelines) - Neutropenia (high risk of infection, ex. cancer) - Other: recurrent UTIs, some STDs (e.g., syphilis)

Combination Therapy (2+ antimicrobials)

• Additive • Synergistic • When is it appropriate? - Severe infections - Mixed infections (multiple organisms) - Preventing resistance - Decreased toxicity (can use lower dose of one or both drugs when using them together) - Enhanced action (one drug enhances effect of another drug) • Can you think of drawbacks of using combination therapy? increase AEs, superinfections, costly, etc.

Determinants of Response

• Bacterial (organism response) • Drug (drug itself, what causes a response) • Host (site of infection)

Mechanism of Action

• Bactericidal - Directly lethal to the bacteria • Bacteriostatic - Slow bacterial growth but the host defenses ultimately eliminate the bacteria -worry about this for immunocompromised patient (choose bactericidal), or for very severe infections

Duration of Therapy

• Based on variables, such as: - Host defenses (ex. immunocompromised needs longer therapy) - Site of infection - Organism (ex. need longer therapy for fungal infection) • Prolonged therapy for certain indications then reassess - Osteomyelitis, endocarditis • Education: instruct patients to complete the entire prescribed course of therapy even when symptoms subside (if they don't, at risk for getting reinfected w something worse)

Drugs Classes for Bacterial Infections

• Beta-lactams - Penicillins - Cephalosporins - Carbapenems • Vancomycin -all weaken cell wall

Drugs Classes for Bacterial Infections

• Beta-lactams - Penicillins - Cephalosporins - Carbapenems • Vancomycin • Tetracyclines • Macrolides • Clindamycin • Aminoglycosides • Sulfonamides • Fluoroquinolones • Metronidazole

Spectrum of Coverage

• Broad spectrum - Think about most common organisms at the source of infection -used for empiric therapy, when don't know exact cause yet; start before get results of test that narrows down organism • Narrow spectrum - Tailor antimicrobial to particular bug that grows from culture - Preferred whenever possible !!

Documenting Allergies

• Drug • Description of reaction • Severity • Temporal relationship between drug exposure and symptoms • Date of occurrence • Has patient had prior exposure to drug or similar agents?

Host Factors

• Immune system (immunocompromised vs immunocompetent); some drugs rely on host immune system to get rid of bacteria • Infection site (can drug get to the site of infection, ex. BBB?) and source factors (ex. foreign object like pacemaker) • Age and/or organ dysfunction - Patient's ability to eliminate the drug • Pregnancy and lactation • Genetic factors • Adherence (if don't finish course of antibiotics, more likely to be re-infected w resistant microbes) • Allergy

Antimicrobial Resistance

• Innate or *acquired* (organism no longer susceptible to antibiotic like it once was) • Associated with extended hospitalization, significant morbidity, and excess mortality • Organisms of concern: - Entorococcus, Staphylococcus, Enterobacter, Pseudomonas, Klebsiella, C. difficile (don't need to memorize these) • Microbe or the patient?

Bacterial Factors

• Match drug to the bug - Drug of choice? (ex. more narrow spectrum, lower toxicity to host, etc.) - Empiric therapy (don't know for certain what's causing infection yet) should be narrowed ASAP (narrow once know organism) - Identification of causative agent * Body fluids such as: blood, sputum, wound drainage * Gram stain (look under microscope) * Culture (grow on a medium) *taking bodily fluid and trying to to determine organism - Obtain BEFORE administering 1st doses of antibiotics if possible (as soon as antibiotics administered, could suppress growth of organism and may not be able to grow culture) - Collect cultures carefully to prevent contamination • Colonization (all of us are colonized by many diff types of bacteria) vs. infection

Dosing Considerations

• Patient weight (even for adult patient!) • Drug penetration (might need higher dose if drug doesn't penetrate site of infection well) • Bioavailability - route • Adherence • *Organ function* - Many antimicrobials are *renally eliminated* (in if declining organ function, standard dose not appropriate)

Macrolides

• Prototype: Erythromycin • MOA: Inhibits protein synthesis - binds to the 50S RNA subunit inhibiting RNA synthesis • Therapeutic Uses: broad spectrum antibiotic (chlamydial infections, pneumonia caused by M. Pneumonia) • Adverse effects- Diarrhea, nausea, abdominal pain - *QT prolongation (with CYP3A4 inhibitors)* • Individual Variation: • Avoid in patients with congenital QT prolongation • *DDIs: strong inhibitor of P450 hepatic enzymes* ► Nursing Implications: • Can take with meals if GI upset occurs (not all forms!) • Instruct patients to complete entire course of therapy

Drug Factors

• Sensitivity testing - Organism on medium tested against multiple drugs - Minimum inhibitory concentration (MIC) - min conc of drug needed to stop growth • Dosage - Can vary substantially by indication • Bioavailability - Can influence route of administration

Sulfonamides AEs & NIs

► AEs: • (allergic) *Rash*, urticaria, photosensitivity, prurutis • Hematologic Effects - Thrombocytopenia, leukopenia, aplastic anemia, *hemolytic anemia (G6PD deficiency)* • Hyperkalemia • Elevation in SCr (renal dysfxn) • *Kernicterus* (neuro disorder, bilirubin in brain) - Avoid in pregnancy, breastfeeding, babies <2 mo. (BBB not fully formed) ►Nursing Implications: • Do not give to patients who are nursing babies under 2 months old • Instruct patients to take the entire course of therapy • Advise use of sunblock/avoid sun, report s/s rash +decrease dose of warfarin

Cephalosporins AEs + NIs

► AEs: • *Hypersensitivity (cross-reactivity with beta lactams)* • N/V/D (>10%) • *Phlebitis* - monitor for • C. difficile colitis (rare) • Other: - Bleeding (cefazolin, ceftriaxone, cefotetan) - Seizures at high doses ► Nursing Implications: • Obtain culture (if ordered) before starting antibiotic • Monitor: - *Phlebitis, rotate injection site, administer diluted medication slowly* - Assess/monitor for allergic reactions, resolution of symptoms, renal function, other AEs • Educate patient to: - Take entire prescribed course of therapy even when they feel better - Report s/s of allergy, wear bracelet - Notify provider if profuse diarrhea (could be c diff colitis)

Contraceptive uses: Combined Contraceptives

► AEs: • Thrombotic disorders • Hypertension • Breakthrough bleeding (e.g., spotting) ► Individual variation: • Avoid: - History or active thromboembolic disease, cardiovascular disease, breast cancers, *smokers and over the age of 35 years old (contraindication!)* - Pregnancy (Category X) ► Nursing Implications: • Assessment/monitoring: monthly breast exam, s/s of VTE, vaginal bleeding (eventually subsides) ► Patient education: • Take pills at the same time each day • Ask pharmacist or provider about what to do if doses are missed (may need backup forms of birth control) • Report s/s of VTE and irregular bleeding/missed periods • DDIs may reduce effectiveness of COC, even OTC/CAMs (e.g, St. John's Wort) - discuss with provider or RPh • Do not smoke (inc risk of VTE)

Non-Contraceptive Use: Estrogen

► AEs: nausea (dissipates over time), VTE, endometrial and ovarian cancers, estrogen-dependent breast cancer ► Individual variation: • History of cardiovascular disease (e.g., stroke, hypertension) • History of cancer (e.g., estrogen dependent breast cancer) • Undiagnosed abnormal vaginal bleeding • Active or history of thromboembolic events • NOT used during pregnancy ► Nursing Implications: • Baseline assessment/monitoring: breast (mammography) and pelvic examination annually, vasomotor symptoms (to discuss efficacy), vaginal bleeding • Patient education: • Monthly breast self-exams (bc inc risk of breast cancer) • Take with food and at bedtime to reduce nausea • Avoid smoking while taking estrogen (inc VTE risk) • Report menstrual changes or s/s of thrombosis (i.e. swelling or redness in legs, shortness of breath, or chest pain) • Variety of products available ( i.e. transdermal patch, intravaginal ring), teach proper administration method

Latent TB Infection vs Active TB Disease

► Active TB • Treating active disease • *Always* treat with two or more drugs for a minimum of 6 months - Minimizes risk for drug resistance - Reduces the incidence of relapse - Selective for M. tuberculosis - do not kill off beneficial microorganisms - Minimal risk of superinfection ► Latent TB (present in body but not active) • Reduces risk of developing active disease • Usually, one drug but could be two drug regimen • Duration depends on medication prescribed

Vancomycin (Vancocin) DDIs, AEs, NIs

► DDIs: aminoglycosides, NSAIDS, cyclosporine (all nephrotoxic) ► AEs: • *Nephrotoxicity* • Ototoxicity (rare) • Phlebitis - always monitor IV site closely • *Vancomycin Infusion Reaction* - *flushing, erythematous rash, pruritis, hives, urticaria, tachycardia, hypotension* *non-immune mediated drug reaction, related to infusion rate, can be prevented by extending infusion time ► Nursing Implications: • Obtain culture (if ordered) before starting antibiotic • *Infuse over at least 60 minutes* (maybe longer to prevent infusion rxn) • Monitor for *phlebitis*, rotate infusion site • *Monitor renal function* • Drug levels (usually a trough) are typically measured to adjust dose (get trough right before dose) • Instruct patients to complete prescribed course of therapy (oral)

Studying

► Do NOT memorize MOA for antibiotics ►You need to know the use (e.g., bacterial infections) ►DOC - drug of choice, need to know this ►How do you know the medication is working? ►How would you educate a patient? ►What are the common AEs? Serious? ►Organ dysfunction? ►How are you administering the medication? ►What re you monitoring? How?

Issues with Prolonged Treatment (months)

► Drug toxicity ► Poor patient adherence ► Emergence of drug-resistant mycobacteria ►Mechanism: - Contact with someone with resistant bacteria - Repeated ineffectual courses of therapy ►Issues: - Use of second-line agents - Longer duration of therapy - Expensive

Urologic Disorders

► Erectile Dysfunction (ED) • Persistent inability to achieve or sustain an erection suitable for satisfactory sexual performance ► Benign Prostatic Hypertrophy (BPH) • Overgrowth of prostate tissue leading to urinary hesitancy, urgency or frequency ► Overactive Bladder (OAB) • Urgency incontinence due to detrusor instability ("cant hold it anymore incontinence")

Medications

► First-line agents: "RIPE" therapy • Rifampin • Isoniazid • Pyrazinamide • Ethambutol

Also required for leuprolide

► Has adequate psychosocial support. ► Assents to treatment, understanding the expected outcomes and the medical and social risks and benefits (as with any medication); ► Some centers require a letter from a mental health provider who has determined that the youth would benefit from gender-affirming hormonal therapy; others centers do not. ► Will take gender-affirming hormones in a responsible manner (as with any medication). ► Has *no contraindications* to gender-affirming hormones (most of which are uncommon in adolescents): -*transgender females* (genotypic males), contraindications include increased risk of venous thromboembolism (VTE), severe liver dysfunction, and estrogen-sensitive tumors. -*transgender males* (genotypic females), contraindications include testosterone-sensitive tumors, polycythemia, and severe chronic liver dysfunction

Tetracyclines

► Individual Variation: • Renal failure • Pregnant or lactating patients • Children under 8 yo ► DDIs: forms nonabsorbable chelates with metal ions (e.g., milk, calcium supplements, antacids) ► Nursing Implications: • Full glass of water to minimize GI upset • Dairy products, iron products and antacids - Administer tetracycline 1 hr before or 2 hrs after chelating agents

Penicillins con't

► Individual Variation: Allergy to PCN or other beta-lactams; *renal dysfunction* (cleared completely through kidneys; ex. don't use in neonates, older adults, CKD) ► AEs: -the safest of the antibiotics, well tolerated besides NVD (but allergy is a concern) • Nausea, vomiting and diarrhea (>10%) • Renal impairment • Electrolyte derangements (with high dose PenG Sodium or Pen G Potassium - hypernatremia, hyperkalemia) • Seizures, confusion, hallucinations (CNS effects) - at high doses - overdose situation - medication errors • *Allergic/hypersensitivity (0.4 - 7%)*

Pyrazinamide

► MOA: • Converts an enzyme pyrazinamide to its active form, pyrazinoic acid, which disrupts bacterial cell membrane - bactericidal ► Therapeutic Uses: • Treatment of active TB - in combination with other anti-TB medications for initial therapy ► Dosage forms: PO ► DDIs: • Enhanced hepatotoxicity effects with rifampin (most hepatotoxic out of all the meds!) • Can interact with some urine tests ► Individual Variation: contraindications • Acute gout, severe hepatic dysfunction ► AEs: • Hepatotoxicity • Polyarthralgia (40%), pain in joints • Other ADEs: *hyperuricemia* (->gout), GI disturbances (N/V/D), rash, photosensitivity ► Nursing Implications: • Monitor serum uric acid • *Risk for DDIs - Extra caution with rifampin • *Avoid alcohol • *Monitor liver function and s/s of hepatotoxicity • *Education and assistance with adherence

Rifampin

► MOA: • Inhibition of bacterial RNA synthesis which consequently results in inhibition of bacterial protein synthesis - bactericidal ► Therapeutic Uses: • Active TB • Latent TB ► Dosage forms: PO, IV ► Safety Issue: • Sound-alike/look-alike: rifaMPIN, rifaBUTIN, rifaPENTINE ► DDIs: • *Strong CYP450 enzyme inducer - can increase metabolism of many drugs (e.g., oral contraceptives (have to go on another non-hormonal BC), HIV meds, warfarin)* ► Individual Variation: • Contra: Concomitant use of certain antiretroviral medications • Cautions: alcohol use or pre-existing hepatic dysfunction ► AEs: • Hepatotoxicity • *Discoloration of body fluids* - red-orange color in urine, sweat, saliva, and tears - Permanent staining of soft contact lenses can occur

Isoniazid

► MOA: • Inhibits synthesis of mycolic acid, an essential component of bacterial cell wall - bactericidal ► Therapeutic Uses: • Active TB • Latent TB ► Dosage forms: PO, IM ► DDIs: • Strong inhibitor of several CYP450 enzymes (ex. seizure med phenytoin) ► Individual Variation: contraindications • Drug-induced hepatitis, acute liver disease ► AEs: • Hepatotoxicity • *Peripheral neuropathy* ► Nursing Implications: • Instruct patients to watch for symptoms of peripheral neuropathy - *Pyridoxine* (Vitamin B6) 50 - 200 mg daily to help w s/s • *Risk for DDIs • *Avoid alcohol • *Monitor liver function and s/s of hepatotoxicity (fatigue, malaise, fever, yellowing of skin/eyes) • *Education and assistance with adherence

Ethambutol

► MOA: • Inhibits the enzyme arabinosyl transferase which impairs mycobacterial cell wall synthesis - bacteriostatic (doesn't kill, just stops growth) ► Therapeutic Uses: • Treatment of active TB - in combination with other agents ► Dosage forms: PO ► Safety Issues: • Sound-alike/ look-alike: Myambutol may be confused with Nembutal ► DDIs: • *Aluminum hydroxide* containing antacids (dec conc of ethambutol): avoid use or administer ethambutol at least 4 hours before ► Individual Variation: • Contraindicated in any patient unable to report visual changes: children, unconscious patients • Requires renal dose adjustments ► AEs: • *Optic neuritis* - blurred vision, constriction of the visual field, and disturbance of color discrimination - Not recommended for children <8 yrs ► Nursing Implications: • Advise patients to monitor for any vision changes • Visual testing and color discrimination tests • *Risk for DDIs - Avoid administration with aluminum containing antacids • *Education and assistance with adherence

Metronidazole (Flagyl)

► MOA: Inhibits nucleic acid synthesis, results in cell death ► Therapeutic Uses: anaerobic bacteria and sensitive protozoans (e.g., Giardia, Trichomonas); *DOC for C. Difficile* (oral vanco second choice, but 10x more expensive) ► Individual Variation: Severe hepatic impairment ►*DDIs: warfarin* ► Adverse effects • Nausea, metal taste in mouth, dark urine, • *Disulfiram-like reaction with alcohol* - flushing, nausea, vomiting, etc. (NO ALCOHOL) • Neuro (rare): CNS excitability, seizures, peripheral neuropathy (more likely if dose not adjusted properly) • Nursing Implications: - Educate patient regarding: • Disulfiram-like reaction with alcohol - flushing, nausea, vomiting, etc. (NO ALCOHOL) • Completing entire course of therapy

Clindamycin (Cleocin)

► MOA: Protein synthesis inhibitor • inhibits 50S subunit inhibiting RNA synthesis ► Therapeutic Uses: anaerobic gram-negative infections, aerobic gram-positive ► Dosage forms: PO, IV, IM ► AEs: GI upset, *C. Difficile associated diarrhea (CDAD)* (most likely drug to cause this!), Increase in AST/ALT ► Nursing Implications: • Give with a full glass so water to minimize GI irritation • Educate patients to: - Report any diarrhea (> 5 watery stools per day) promptly to provider - Complete full course of therapy

Vancomycin (Vancocin)

► MOA: binds to bacterial cell wall and inhibits peptidoglycan synthesis ► Therapeutic Uses: susceptible *gram+ bacterial* infections • *DOC: Healthcare-associated MRSA* • *Serious* staphylococcal infections (when allergy to beta lactams) • *C. Difficile (Oral only)* ► *PK: not absorbed orally* - stays in GI tract, which is why it's used for C diff ► Dosage forms: IV, Oral ► Individual Variation: *renal dysfunction*

Meds for Gynecologic Conditions

► Non-Contraceptive Uses (menopause) • Conjugated equine estrogens • Medroxyprogesterone ► Contraceptive Uses • Estrogen-progestin combination contraceptives • Progestin only contraceptives • Emergency contraceptives

Penicillin Allergy

► Not related to size of dose, prior exposure necessary ► Cross sensitivity to: • All Penicillins, possibly to cephalosporins and carbapenems (other beta lactams); if anaphylaxis, be careful w other beta lactams ► Manifest as rash to life-threatening anaphylaxis • Immediate reactions (anaphylaxis) are IgE mediated reaction (bronchoconstriction, severe hypotension, laryngeal edema) • Incidence low ~ 0.004 - 0.04%; however, mortality about 10% • *Treatment: Epinephrine plus respiratory support*

Rifampin NIs

► Nursing Implications: • Administer 1 hour before or 2 hours after meals - Absorption is decreased if given with food • Inform patients of expected orange-red color of urine, saliva, sweat, and tears • *Risk for DDIs (ex. warfarin) • *Avoid alcohol • *Monitor liver function and s/s of hepatotoxicity • *Education and assistance with adherence

Penicillins NIs

► Nursing Implications: • Allergy • *Always* assess allergies prior to administration • Monitor for allergic reaction for 30 minutes after administration (IV) • Monitor for resolution of symptoms (fever, pain, lab values), renal function (must evaluate), allergy, AEs • DDI: not compatible with aminoglycosides (gentamicin); can be ordered together but can't be administered together!! • Obtain culture (if ordered) before starting antibiotic • Patient Education - Take entire prescribed course of therapy even when they feel better - Report s/s of allergy (skin rash, itching, hives) - Wear ID bracelet if penicillin allergic

Testosterone NIs

► Nursing Implications: • Assessment/monitoring: acne, virilization, weight, abuse potential • Patient education • *Administration varies by route, education on administration is important* • Rotate site of injection for IM formulation or patches • Gel: wash hands after use; avoid contact with other people immediately after use (skin to skin transfer); no showering or swimming within 6 hours of application (dec effectiveness) • Buccal - applied above incisor (30 seconds), eating does not affect drug absorption, but does leave a taste, kissing can transmit drug

Carbapenems NIs

► Nursing Implications: • Obtain culture (if ordered) before starting antibiotic • Assess/monitor for: - allergic reactions, resolution of infection symptoms, renal function, superinfections • Recognize DDI with valproic acid - 50 to 80% drop in blood levels of valproic acid - Occurs rapidly within 24 hours - May lead to seizure activity - Other team members miss this DDI.

Alpha1-adrenergic antagonists

► Nursing implications: • Assessment/monitoring: monitor blood pressure, especially at the start of therapy and with dose changes • Administration • Tamsulosin should be taken 30 minutes after a meal at the same time each day • Swallow capsule whole and do not crush, chew, or open it • Patient education: Advise patient to rise slowing from a sitting/lying position to avoid orthostatic hypotension

Directly Observed Therapy (DOT)

► Patient nonadherence - most common cause of treatment failure or drug resistance ► DOT - standard of care for TB • Administration of each dose in the presence of an observer to make sure take every dose • Allows ongoing evaluation of the clinical response and adverse drug effects.

Contraceptive Uses

► Products containing synthetic estrogen and/or progestin ► Preparations: • Estrogen/progestin combination products - Mono/bi/tri/quadriphasic products (aka. COCs, combined oral contraceptives; have estrogen and progestin) - Extended cycle products (don't have menstrual cycle for extended period) - Transdermal patch - Vaginal contraceptive ring • Progestin only products - Oral, referred to as "minipills" - Parenteral (IM and SubQ) • Implants and IUDs (highly effective!)

Contraceptive Use: Emergency Contraception

► Prototoype: levonorgestrel (Plan B One-Step) ► MOA: delay or stop ovulation, may also prevent implantation ► Dosage form: oral ► AEs: heavier menstrual bleeding, nausea, abdominal pain, headaches and dizziness ► Dosage forms: tablet (1.5 mg), OTC ► Nursing implications: • Baseline assessment: pregnancy test • Patient education: most effective within 24hrs and <72h and ineffective after fertilization has occurred

Fluoroquinolones

► Prototype: Ciprofloxacin (Cipro) ► MOA: Protein synthesis inhibitor • inhibits bacterial DNA topoisomerase causing breakage ofDNA strands ► Therapeutic Uses: Broad spectrum - infections of lower respiratory tract, inner ear, soft tissue, and bone; UTI ► Individual Variation: renal impairment, myasthenia gravis (can cause added muscle weakness) ►*DDIs: Many!* ► AEs: • *Tendonitis & tendon rupture* (starts at pain, swelling, inflammation; report to provider) • *Phototoxicity* • Dizziness or lightheadedness • QT prolongation ► Nursing Implications: • Dairy products, iron products and antacids- Administer fluoroquinolones no sooner than 6 hours after chelating agents • Educate: s/s of tendon damage; use sunscreen; DDIs

Carbapenems - name recog = -penem

► Prototype: Imi*penem* (Primaxin) ► MOA: binds to bacterial cell wall and inhibits peptidoglycan synthesis ► Therapeutic Uses: *extremely broad spectrum* for bacterial infections caused by *highly resistant organisms* ► AEs: N/V/D, *seizures (rare, lowers seizure threshold)*, hypersensitivity reactions, super infections ► DDI: *Decreases valproic acid (antiepileptic) levels* ► Individual Variation: *Renal dysfunction* ► Dosage Form: IV Only

Tetracyclines

► Prototype: Tetracycline ► MOA: Protein synthesis inhibitor • reversible binding to 30S ribosomal subunit blocking attachment of transfer RNA to an acceptor site on the messenger RNA ribosomal complex ► Therapeutic Uses: Atypical organisms (Rickettsia, spirochetes); Lyme disease, Acne; Peptic Ulcer Disease; Periodontal disease ► AEs: GI irritation; *dental effects (discoloration) in children (not for children <8 yo; also don't use in pregnancy, can be exposed in utero); photosensitivity* (use sunblock/stay out of sun); vestibular symptoms - dizziness, headache, vertigo (especially Minocycline), superinfection

Sulfonamides

► Prototype: Trimethoprim/Sulfamethoxazole [TMP/SMX] (Bactrim) ► MOA: Interferes with bacterial folic acid synthesis by competitively inhibiting p-aminobenzoic acid utilization ► Therapeutic Uses: UTIs; Pneumocystis Pneumonia(PCP) ► Individual Variation: renal dysfunction, Allergy to any sulfonamide ► DDIs: *Warfarin - metabolism is inhibited, resulting in increased INR*, increased bleeding risk

Non-Contraceptive Use: Estrogen

► Prototype: conjugated equine estrogens (Premarin) ► MOA: steroidal hormone that acts in the cell nucleus to produce a variety of effects on reproductive and nonreproductive tissues ► Therapeutic Use(s): • *Hormonal replacement therapy (HRT)* • Female hypogonadism, acne ► Dosage forms: • *Oral* • Transdermal • Intravaginal (if only having local effects) -oral/transdermal if more systemic effects like hot flashes, night sweats

Contraceptive Uses: Combined Contraceptives

► Prototype: ethinyl estradiol and norethindrone ► MOA: stop conception by preventing ovulation. Also thicken the cervical mucus and alter the endometrial lining to reduce the chance of fertilization ► Therapeutic use(s): • *Prevent pregnancy* • Acne • Cycle regulation ► Dosage forms: oral, transdermal, intravaginal ► *DDIs: CYP450 inducers (e.g., rifampin, St. John's Wort)* can reduce effectiveness!!

5-alpha reductase inhibitors

► Prototype: finasteride (Proscar, Propecia) ► MOA: decrease usable testosterone by inhibiting the converting enzyme, causing a reduction of the prostate size and increased hair growth ► Therapeutic use(s): BPH, male pattern baldness ► Dosage forms: oral ► DDIs: no significant drug interactions ► AEs: decreased libido and ejaculation, gynecomastia

Non-Contraceptive Use: Progestin

► Prototype: medroxyprogesterone (Provera) ► MOA: steroidal hormone that acts in the cell nucleus to produce a variety of effects on reproductive and nonreproductive tissues ► Therapeutic use(s): *HRT* (in combination with estrogen in patients with intact uterus), won't be tested on these uses: dysfunctional uterine bleeding, amenorrhea, infertility ► Dosage forms: Oral, IM, subQ, intravaginal, transdermal ► AEs: gynecologic effects (e.g. breakthrough bleeding, spotting and amenorrhea), breast cancer (postmenopausal women), VTE (moreso w estrogen, but they're often coformulated), edema, jaundice

Contraceptive Use: Progestin-only

► Prototype: norethindrone ► MOA: alter cervical secretions and modification of the endometrium ► Therapeutic use(s): prevent pregnancy ► *Dosage forms:* • Oral (aka. minipills) • IM, SubQ (i.e., Depo-Provera) • Intrauterine (IUD) • Subdermal implants ► AEs: menstrual irregularities (e.g. breakthrough bleeding, amenorrhea, hypermenorrhea) -reasons for being on progestin only: contraindication to estrogen, breastfeeding ► Nursing Implications: • Assessment/monitoring: breast exam, pregnancy test, s/s of VTE, vaginal bleeding ► Education: • Should be taken continuously, use on day 1 of menstrual cycle • Dosing should be done at the *same time each day* • If one or two doses are missed, take as soon as possible and use backup birth control for 2 days

Phosphodiesterase-5 inhibitors

► Prototype: sildenafil (Viagra) ► MOA: enhanced blood flow to the corpus cavernosum leading to penile erection ► Therapeutic use(s): ED, pulmonary arterial hypertension (of neonate), BPH (vardenafil only) ► Dosage forms: oral ► DDIs: *nitroglycerin*, grapefruit juice (inhibit metabolism), drug that lower blood pressure ► AEs: • *Hypotension/dizziness*, flushing, dyspepsia, nausea, headache, angina ► Individual variation: *avoid use with any nitrate drug*, use with caution in those with history of cardiovascular diseases (might be on nitrate, might not be suitable for sex d/t underlying heart condition) ► Nursing Implications: • Assessment/monitoring: evaluate for cardiac disease, recent use of nitrates and alpha blockers • Patient education: • Take ~ 1 hour prior to sexual activity, high fat meals may inhibit absorption • Seek medical care for erections lasting 4+ hours, ED immediately • *Do NOT use nitrates within 24 hours of use of these medications*

Alpha1-adrenergic antagonists

► Prototype: tamsulosin (Flomax) ► MOA: relaxing smooth muscle of the bladder neck and prostate (uroselective) by blocking alpha1 receptors ► Therapeutic Use(s): BPH ► Dosage forms: oral ► DDIs: antihypertensive medications (additive effects), *PDE-5 inhibitors* (used for ED; can cause hypotension/dizziness as well) ► AEs: hypotension/dizziness, nasal congestion, sleepiness, faintness, *problem with ejaculation, floppy iris syndrome after cataract surgery*

Testosterone

► Prototype: testosterone ► MOA: androgen steroid that promote sex traits in men and the production and maturation of sperm, as well as, anabolic and erythropoietin effects ► Therapeutic use(s): male hypogonadism, *replacement therapy* (deficiency in erectile dysfxn) ► Dosage forms: oral, IM, buccal, SubQ (implantable pellets), and transdermal (gel, patch, topical solutions) -often gel, oral has large first pass effect ► DDIs: oral anticoagulants, insulin and antidiabetic agents, hepatotoxic agents ► AEs: • *Hepatotoxicity*, edema, polycythemia, premature epiphyseal closure, increase LDL (monitor cholesterol) • *Androgenic effects (aka. virilization)* • In females: amenorrhea, deepening of voice, clitoral enlargement, acne, hirsutism, weight gain, baldness • In males: gynecomastia, priapism, acne, hirsutism ► Individual variation: *Avoid* • Pregnancy • Prostate cancer • Breast cancer

Anticholinergic Agents

► Prototype; Oxybutynin (Ditropan XL, Oxytrol, Gelnique) ► MOA: Anticholinergic, acts primarily at M3 muscarinic receptors inhibiting bladder contractions and the urge to void ► Therapeutic Use(s): OAB (overactive bladder), BPH ► *AEs: Anticholinergic effects* ► Drug interactions: CYP3A4 inhibitors/inducers ► Dosage forms: • Short acting: syrup and tablets • Long-acting: Extended-release tablets, transdermal patch and gel (lowest incidence of AEs)

Cephalosporins (name recognition = ceph- or cef-)

► Prototypes: Cephalexin (Keflex) [PO]; cefazolin (Ancef) [IV] ► MOA: Binds to penicillin binding proteins; inhibiting cell wall synthesis and causing cell wall lysis ► Therapeutic Uses: Susceptible *bacterial* infections (treatment and prophylaxis) • Examples: STIs, AOM, *surgical prophylaxis* -works against gram positive organisms often found on skin like staph and strep ► Dosage Forms: IV/IM, PO (only 9 available orally in US) ► Individual Variation (very similar to penicillins): • *Renal dysfunction* (almost completely cleared through kidneys) • Hepatic dysfunction (ceftriaxone ONLY) • Allergy to cephalosporins (or other beta-lactam antibiotics)

Anticholinergic Agents

► RN implications: • Do not crush ER tablets • Patch considerations • Gel - Wash hands well after application - Do not shower for at least 1 hour - Can transfer to others, cover with clothing • Methods to prevent anticholinergic AEs (dry eyes/mouth, blurred vision, urinary retention, constipation)

Summary

► Rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) are the first-line medications for the treatment of TB. ► Hepatotoxicity is a major concern with anti-TB medications- always monitor liver function. ► Multidrug regimen is important to decrease the risk of resistance with anti-TB medications. ► Patient assessment and education for drug-specific AEs, individual variations, and DDIs is crucial. ► Drug burden and duration of therapy varies between latent vs active TB. ► Second-line agents are reserved for resistant TB infection

Aminoglycosides NIs

► Traditional dosing • Usually q8h dosing, although could be q24h if poor renal function • Levels (traditional dosing): - Trough - just before next dose - Peak - 30 minutes *after* 30-minute infusion ► Extended-interval dosing • Once daily dosing, *ONLY* appropriate for patients with normal renal function • Decreases risk of nephrotoxicity • Obtain trough drug levels only (goal is <1 mg/dL) ► Nursing Implications: • Note exact time of administration and when levels drawn • Monitor for ototoxicity & nephrotoxicity

GnRH Analog: Leuprolide (Lupron)

►*MOA*: agonist of gonadotropin releasing hormone (GnRH) receptors. Acting as a potent inhibitor of gonadotropin secretion ►*Treatment*: suppression of puberty (Precocious puberty >2); indicated before the onset of puberty • also used for treatment of endometriosis, fibroids, and advanced prostate cancer ►*Forms*: depot (given at 1 or 3 month depot formulations); SQ; do not give IV ►*AE: growth suppression*, diabetes, weight gain • Pregnancy category X ►*Nursing Implications*: • GnRH testing (blood LH and FSH levels), • Measurement of height and bone age every 6 to 12 months, • Testosterone in males and estradiol in females (If given IM depot monthly - check every 1-2 months or with dose change) • Bone mineral density (baseline and yearly) • **Note: if stated later, other AE may occur

Testosterone

►*MOA*: works within the DNA ►*Therapeutic Use*: Promote masculinization of individual (female birth assigned sex; but identifies as a male; or F-M); therapy usually started age 16 • Traditionally, testosterone is responsible for: transformation of secondary sex characteristics, growth of skeletal muscle, promotion synthesis of erythropoetin • Transgender men: Hair growth on face/body; deepening of voice, weight gain, clitoral enlargement, breast tissue atrophy, cessation of menses, male patterned baldness

Penicillin Safety Concerns

►Dosage forms mix ups • Certain long-acting formulations ONLY administered by intramuscular (IM) route - Penicillin G Benzathine - Penicillin G Procaine ►Toxicity in overdose scenario (CNS effects like seizures) or severe renal dysfunction

Testosterone

►Forms: patch, gel, IM/SQ (see also oral, buccal) • IM/SQ: Testosterone Cypionate 20 mg given once a week • Patch: applied daily (at night) (1-2 mg) • Gel: applied in morning after shower (cover the area so don't transfer to others) ►*AE: hepatoxicity, edema, polycythemia*, premature epiphyseal closure, lower HDL (good cholesterol) and elevate LDL, acne ►Contraindicated in pregnant women, unintended virilization with children come in contact with unwashed clothing

Testosterone con't

►Nursing Implications: - The prescribing healthcare provider should monitor the patient for intended masculinizing effects and adverse effects every 3 months for first year and then every 6-12 months - Height/weight (every 3 months for first year) - Yearly: Renal function, hct (bc of testosterone's role in RBCs), liver function, lipids, glucose, insulin, hemoglobinA1C - Testosterone levels (adherence); low testosterone assoc w dec insulin sensitivity • Must assess whether the individual is having sex, in that testosterone therapy will not prevent pregnancy; contraception must be discussed

Aminoglycosides

►Prototype: Gentamicin ►MOA: Protein synthesis inhibitor • binds to the 30S ribosomal subunit and irreversibly inhibit bacterial RNA synthesis ►Therapeutic Uses: serious gram-negative infections; gram positive infections for *synergy only* ►DDIs: ototoxic drugs (ex. loop diuretic), nephrotoxic drugs (ex. vanco), skeletal muscle relaxants ►Individual Variation: renal dysfunction (need dose reduced; plus drug levels always monitored/titrated for this drug); drug interactions ► AEs: • Nephrotoxicity • Ototoxicity (about 50% is irreversible) - COCHLEAR high tone hearing is affected first, audiograms are usually needed to detect early cochlear damage, the toxicity may progress, however, and total deafness is possible. - VESTIBULAR dizziness, headache, vertigo, tinnitus -monitor trough levels; ototoxicity assoc w high trough levels -trough level: lowest level in body after drug redosed; draw 5-30 mins prior to next dose • AG-induced NM blockade (don't use w other NM blockers, paralysis)

Transgender Health: Drug Therapy

►Puberty suppression: Gonadotropin Releasing Hormone Analogs (GnRH) ►Testosterone ►Spironolactone (Anti-androgen) ►Estrogen