Important Info 2

Migraine Tx: Prescription (Triptans-1st line for acute tx)

Triptans are selective for 5HT1 receptor Agonist & cause vasoconstriction of cranial blood vessels, inhibit neuropeptide release & decrease pain transmission -Should be taken @ first sign of migraine Rizatriptan (Maxalt-MLT): Tablet/ODT Sumatriptan: SC autoinjector prefilled syringe & soln, nasal spray Imitrex: Tablet, Nasal Spray- do not prime, SC injection Imitrex STATdose System, Zembrace Symtouch- SC inj Onzetra Xsail: Nasal powder Zolmitriptan (Zomig ZMT): ODT, Nasal spray Notes: ODT, Nasal Sprays, & Injections for Nausea -Maxalt MLT & Zomig should not be used with phenylketonuria -Almotriptan tabs, Zolmitriptan nasal spray, & Treximet approved for >=12 yo, Rizatriptan 6-12 yo Frovatriptan (36h) & Naratriptan= Longest Half Life Warning: increase in BP, Serotonin Syndrome; Sumatriptan, Rizatriptan, & Zolmitriptan are CI with MAOis Tablets: ALL ODT: Zomig ZMT & Maxlat MLT Nasal Spray: Imitrex, Zomig Nasal Powder: Sumatriptan (Onzetra Xsail)= instill nose piece in 1nostril, rotate device to place mouth piece into your mouth, blow for 2-3s, discard 1st nose piece, repeat on other side with 2nd nose piece SC: Prefilled-Sumatriptan; Autoinjector Sumatriptan (Imitrex STATdose System, Zembrace Symtouch)

Types of ADRs/Drugs Associated with Photosensitivity/TTP

Type A: Most rxns (dose dependent & predictable) Type B: Idiosyncratic (not predictable) - Can be influenced by patient specific factors -Ex) Rash with Lamotrigine, Abacavir, SJS *Include: Drug allergies, Pseudo-allergic rxns Type I rxns: immediate within 15-30 min Type II rxns: minutes to hours Type III rxns: 3-10hrs after drug exposure Type IV rxns: delayed; 48h- several weeks Drugs Associated with Photosensitivity -Amiodarone, Diuretics (thiazide, loop), MTX, Oral & topical retinoids, FQs, St. John's Worth, Sulfa, Tacrolimus, Tetracyclines, Voriconazole, NSAIDs Thrombotic Thrombocytopenic Purpura (TTP): blood disorder in which clots form throughout the body- should be immediately tx with plasma exchange -Papules= raised spots; Macules= flat spots -Purpura: red/purple skin spots due to bleeding underneath skin Drugs associated with TTP -Oral P2Y12 inhibitors, Sulfamethoxazole

Common Travelers Infections

Typhoid Fever: Salmonella Typhi, contaminated by feces; Typhoid vaccines recommended (50-80% effict) *Vivotif-oral live, attenuated vaccine (1wk prior), Thyphim Vi- IM, >= 2 wks before expected exposure Cholera: Vibrio Cholerae, rice water stools, -Live attenuated vaccine (Vaxchora) Polio: Single life time booster (international certificate of vaccination prophylaxis) Yellow fever: reduce mosquito exposure, Aspirin & NSAIDs cannot be used due to bleeding risk; vaccine 10 days before travel Inactivated vaccines: 1)Hepatitis A (Havrix) 2)Hepatitis B (Engerix B, Recomb HB) 3)Hepatitis A/B 4)Japanese Encephalitis 5) Meningococcus, Polio, Typhoid IM Live: Cholera PO, Typhoid PO, Yellow fever (YF-VAX)

Pregnancy & Lactation

Updated Pregnancy Section: Pregnancy: Risk of adverse development outcomes Lactation: Whether the drug/metabolites are present in human milk Females & Males of Reproductive potential: Effects on fertility & requirements for pregnancy & contraception Drug tx: Inactivated influenza vaccine, single dose of Tdap with each pregnancy Teratogenic Drugs: Acne: Isotretinoin, topical retinoids Abx: FQs, Tetracyclines Anticoagulants: Warfarin (mechanical valve switched back from Enoxaparin to Warfarin @ 13 weeks) Dyslipidemia, HF & HTN: Statins, ACE/ARBs, Aliskiren, Entresto Hormones: Raloxifene, Duavee, Testosterone, Estradiol Migraine: Dihydroergotamine, Ergotamine Others: Hydroxyurea, Lithium, MTX, Misoprostol, NSAIDs, Paroxetine, Ribavirin, Thalidomide, Topiramate, Valproic Acid/Divalproex

H2blockers

Use in caution with CNS depressants (especially in dementia) due to risk of additive delirium, dementia, & cognitive impairment - use lower doses in renal probs

Sjorgen's Syndrome/Psoriasis

Sjorgen's Syndrome: dry eyes & mouth Tx: Cyclosporine eye drops (Restasis)- ocular burning Lifitegrast (Xiidra): unusual taste Mouth- Pilocarpine, Cevimeline Psoriasis -Raised red patches covered with silvery white buildup -Non drug: UV light= causes T cells in skin to die -Topical: Steroids, Coal Tar products -Systemic: Retinoids, Phosphodiesterase 4 inhibitors Interleukin Receptor antagonist

Eye and Ear Formulations/ Glaucoma

Solutions: 1 drop=0.05 ml Suspension: shake well Ointments: apply to the conjunctival sac or over lid margins (blepharitis), can cause blurry vision, do not use with contacts Gels: with cap on, invert & shake once to get the medication into the tip before instilling into eye Glaucoma: damage to the optic nerve & loss of visual field- most cases IOP above normal range 1) Open angle= more common, eye drops 2) Closed angle= medical emergency Drugs that can increase IOP -Anticholinergic (oxybutynin, tolterodine, benztropine, trihexyphenidyl, TCSs), Cough/Cold/Motion sickness (Antihistamines, Scopolamine), Chronic steroids, Topiramate Glaucoma Tx Goal: Decrease IOP -Reduce aqueous humor production (make less fluid) *Beta blockers, like timolol -Increase aqueous humor outflow: Prostaglandin, Latanoprost -Or do both: often achieved with ad on tx: Alpha 2 agonist like brimonidine

Garbing for sterile vs hazardous

Sterile: 1) Remove coats, rings, makeup 2)Head & facial covers & face mask- then shoe covers while stepping over line of demarcation, 2nd pair needed for hazardous; an eye shield is optional, except if preparing hazardous 3)Perform hand hygiene with soap & warm water- under warm water clean under fingernails, working from finger tips to the elbows, wash vigorously in circular motion for 30s, dry hands & forearms with lint free disposal towels 4) Non shedding gown= disposal are required for HD 5)Enter buffer area (SEC), apply alcohol based surgical hand scrub 6)Sterile powder free gloves, Two pairs for HDs (1 pair under the cuffs, 2nd pair over cuffs 7)Sanitize gloves with 70% IPA routinely

Opioid Allergy/OIC

The common drugs in the same class cross react: "Cod", "Morph", or "Norph" Make sure it is a true allergy & not itching & nausea -Codeine, Morphine, Hydrocodone, Hydromorphone, Buprenorphine, Oxycodone, Oxymorphone, Heroin *All opioids except Oxymorphone should be taken with food to lessen nausea -Unlike CNS depression, OIC does NOT improve over time = Stimulant laxatives, PAMORAS, Lubiprostone Peripherally acting Mu Opioid Receptor Antagonist -Block opioid in the gut to reduce constipation without affecting analgesia Methlynaltrexone (Relistar), Naloxegol (Movantik), Naldemidine = warning GI perforation, abdominal pain

Thyroid

Thyroid Production is regulated by Thyroid Stimulating Hormone (TSH) T3 is more potent than T4= shorter half life Hypothyroidism: Deficiency in T4= most common cause is Hashimoto's an autoimmune condition in which a patients own antibodies attack thyroid gland -Myxedema coma: fatal complication of hypothyroidism= IV levothyroxine Diagnosis: Low T4 (normal 0.9-2.4), High TSH (0.3-3) -Monitor every 4-6 weeks until normal

Contraceptive ADEs

-Drug interactions that decrease hormonal contraception's: Inducers PS-CROPS -Risk with Hepatitis C: Technivie & Viiekira Pak= increased liver toxicity Missed doses COCs: 1 late <48h (take missed as soon as possible no back up needed; >=48 discard missed dose & back up for 7 days POPs: if >= past schedule , take as soon as you remember, back for 48h; Intrauterine Devices (Mirena, Skyla, Kyleena, Liletta): -IUDs that contain progestin levonorgestrel. Mirena is FDA approved for heavy menstrual bleeding -The copper T (Paraguard): EC/ or reuglar birth control -The Nexplanon: progestin etonogestrel 3 yrs

Hormonal Contraceptives

-FDA requires Patient Package Insert (PPI) to be dispensed with oral contraceptives -Most COCs contain Estrogen Estradiol (EE) & Progestin (Norethindrone, Levonorgestrel, Drospirenone) -Mono phasic: same dose of estrogen & progesterone -Biphasic/Triphasic/Quadriphasic mimic the estrogen & progesterone levels -COCs other indications: Dysmenorrhea, Premenstural Syndrome (PMS), Acne, Anemia, & Menstrual associated migraine, Polycystic Ovary Syndrome, Endometriosis -Drospirenone is unique progestin used in COCs to reduce ADEs- Mild K sparing diuretic, decreases bloating, PMS, & weight gain, less acne; Yasmin 28; -Progestin ONLY pills: used in breastfeeding, require good adherence, must be taken within 3 hrs of scheduled time, safe in Migraines w Aura; Erin, Camila, Nora BE, Slynd=Drospirenone only -Contraceptive Patch: higher systemic estrogen, do not use in anyone with clotting risk factors, Less effective in women >198 lbs (Xulane), do not use in >35yo+ smoke

Increased COX-2 Selectivity/Salicylate NSAIDs

-Lower risk for GI complications (but still present); increase risk MI/stroke (avoid with CV risk; avoid high doses & longer duration in pts at risk for CV, same renal complications -Celecoxib (Celebrex): CI- Sulfonamide allergy; Highest COX-2 selectivity -Diclofenac (Voltaren): Total body max 32g.day, Flector 1 patch BID; Avoid in women of childbearing potential -Meloxicam (Mobic); Nabumetone Salicylate NSAIDS -Aspirin/Acetylsalicylic Acid (Ascriptin, Bufferin, Ectorin) -Cardio protection (81-162 mg once daily); avoid in children with viral infection-Reye's Syndrome; overdose= tinnitus = caution with other ototoxic agents-AMGs, IV loop -If using aspirin 1 hour before or 8hrs after ibuprofen -NSAIDS can increase lithium & mtx levels

Hyperthyroidism

-Most common cause: Graves Disease -Drug induced causes: Iodine, Amiodarone, Interferons Tx: Thionamides: inhibit synthesis of thyroid hormones by blocking the oxidation of iodine in the thyroid gland; PTU also inhibits peripheral conversion of T3 to T4 -Propylthiouracil (PTU): -Methimazole Notes: Pregnancy PTU preferred in 1st trimester, Methimazole 2nd & 3rd trimester -Severe Liver Injury & Acute liver failure , DILE, Take with food GI upset Iodides: Temporary inhibit secretion of thyroid hormones; T4 & T3 levels will be reduced to several weeks but effect will not be maintained Potassium Iodide blocks accumulation of radioactive iodine to prevent thyroid cancer

Centrally Acting Analgesic

-Mu receptor agonists & inhibitors of norepinephrine reuptake. Warning-Seizure risk; serotonin syndrome; do not use in children <12 or <18 yo with tonsillectomy Tramadol (Ultram): C-IV Tapentadol (Nucynta ER): CII -Avoid CYP2D6 inhibitors; increases Warfarin INR Treatment of over dose: see pic Buprenorphine partial mu opioid agonist at lower doses & antagonist at higher doses; CIII, patch-change weekly; disposal=fold sticky sides together flush; ADEs for patch=dizziness, headache, application site rxns, nausea; notes= to prescribe for opioid dependence prescribers need DATA 2000 waiver with start w X Naloxone is opioid antagonist- replaces the opioid on the mu receptor; acute withdrawal symptoms, repeat dosing can be required

BUD

-Nonaqueous (drug in petrolatum): no later than 6 months (180 days-room temp) -Water containing oral formulations (no later than 14 days when stored at cold temps -Water containing topical/dermal/mucosal liquid: 30 days store at room temp

Compounding Area

-Primary Engineering Control (PEC or sterile hood or isolator): 5 (3520 particles) -Secondary Engineering Control (SEC, called buffer room) Anteroom if it opens into a negative pressure SEC: 7 (352,000) -Ante room if it opens to positive pressure: 8 *Anteroom: handing washing, garbing

Traveler's Diarrhea Treatment

-Prophylaxis: Bismuth Subsalicylate 524-1050 mg po 4 x a day (with meals @ bedtime) -Abx (Rifaximin preferred): only used if there is a high risk of complications from TD Treatment: Mild: Loperamide or Bismuth Subsalicylate Moderate: Loperamide +- abx (FQ if low resistance, azithromycin or rifaximin) Severe: Abx (azithromycin preferred, FQ, or Rifaximin as alternative +- loperamide

H. pylori treatment

-Quadruple therapy first line; use of triple therapy first line is only recommended if Clarithromycin resistance rates are low <15%; do not make substitutions Bismuth Quadruple Therapy: 10-14 days Bismuth QID+ Metro QID+PPI BID or (Esomeprazole/d) + Tetracycline Pylera (Bismuth +Metro +Tetracycline)+ PPI -Take as separate rx for acid reducing meds -3 caps x 4/day with full glass of water Other: Quadruple Amoxicillin+ Clarithromycin+ Metro+ PPI BID Triple: Amoxicillin+ Clarithromycin +PPI BID Prevpac: Amox + Clarithromycin + Lansoprazole -Each card has your dose (4 pills) for the morning & evening- before breakfast and dinner

Rx Migraine Prophylaxis:

-Some meds decrease the frequency, consider if pt uses acute tx >=2days/week or >=3x per month, if migraine decreases their quality of life, or acute infective -Propranolol (Inderal LA, XL)- most lipophilic; Metoprolol Tarte (Lopressor); Metoprolol Succinate ER *ADEs: exacerbate Raynaud's, impotence, bradycardia -Divalproex (Depakote ER/Sprinkle): fetal harm, weight gain, thrombocytopenia, increase ammonia, alopecia -Topiramate (Topamax): Fetal harm, nephrolithiasis, ammonia, open angle glaucoma, oligohidrosis, cognitive impairment Calcitonin Gene Related Peptide (CGRP) Antagonist -Human monoclonal antibodies; approved for prevention; Rimegepant (Nurtec)- ODT Botox: Chronic migraine only (>=15 headaches/mo)

COPD

-Symptoms: Dyspnea- chronic & progressive, chronic cough, sputum production & wheezing -Caused by tobacco smoke & other pollutants -Long term exposure= chronic inflammation (Emphysema & Bronchitis) -Spirometry is required to assess lung function & make diagnosis of COPD -COPD airflow usually not fully reversible -Post Bronchodilator FEV1/FVC <0.7 confirms a diagnosis of COPD

Compounding Basics

-USP: sets the standards for compounding preparations; refers to a list of medicinal drugs, with preparation instructions -USP does not determine which drugs are safe HDs -USP 795 (non sterile ), 798 (sterile), 800 (HDs)= minimum acceptable standards (FDA, state boards of pharmacy, & Joint Commission) -National Institute for Occupational Safety & Health (NIOSH): determines which drugs are hazardous ; keeps a list of all HDs= NIOSH List of Antineoplastic & Other Hazardous Drugs in Healthcare Settings

Systemic Lupus Erythematosus (SLE)

-Women & AA/Asian descent at higher risk -Presentation: Fatigue, Depression, Anorexia, Weight loss, muscle pain, malar rash (butterfly), photosensitivity, joint pain; arthritis, neurologic, kidney disease TX: Hydroxychloroquine, Cyclophosphamide, Azathioprine, Mycophenolate Mofetil, Cyclosporine Belimumab (Benlysta): do not give other DMARDS,PML Select drugs that can cause DILE: My Pretty Pony Miss Queen Muffin Is A Terrific Horse Methimazole, Propylthiouracil, Procainamide, Methyldopa, Quinidine, Minocycline, Isoniazid, Anti TNF, Terbinafine, Hydralazine (BiDil)

Vaccine preventable childhood disease

1)Measles: White spots on the side of cheeks; koplik spots in mouth, airborne 2)Mumps: Swollen & Tender salivary glands under the ears 3)Rubella: A fine, pink rash that begins on the face & quickly spreads to the rest of the body 4)Polio: child with poliomyelitis- nerve damage 5)Pertussis: whooping cough 6)Rotavirus: Diarrhea, Fever, Vomiting 7)Chicken pox (varicella): rash

Anti-TNF Biologic DMARDs

1. Adalimumab (Humira): SC every other week, thigh or abdomen 2. Infliximab (Remicade) +MTX 3. Etanercept (Enbrel): SC weekly, ab, thigh ,upper arm 4. Certolizumab Pegol (Cimzia) 5. Golimumab (Simponi) +MTX; filter, monthly BB: Serious infections, TB, Malignancies, Warning-demyelinating disease (hep B reactivation), heart failure, lupus like syndrome; do not shake or freeze-fridge ok -Humira & Enbrel can be stored at room temp 14 days Other biologics: (Non TNFi) Rituximab (Rituxan)+ MTX: Depletes CD20, pre-medicate with steroids & acetaminophen and antihistamine

Opioids

All opioids- constipation, N/V, somnolence, dizziness/light headiness & respiratory depression; pruritus is common in opioid naïve pts (use Benadryl) Codeine: CII- Codeine tabs; CIII tabs/caps combo; CV- oral soln combos, do not use <12 yo & <18 with tonsillectomy Fentanyl (Duragesic, Sublimaze): CII; Actiq oral trans mucosal lozenge; not used in opioid naïve pts- can use if morphine 60mg/d or equivalent for at least 7 days -Apply to hairless skin, can be covered with Bioclusive or Tegaderm, do not cover with heating pads, dispose the patch in toilet, keep away from children Methadone (Dolophine): QT prolongation, Variable half life, decreases testosterone MepeRidine (Demerol): Renal impairment/elderly at risk for CNS toxicity= no longer recommended; short duration, seizures, in combo can be serotonergic *CYP3A4 substrates= Hydrocodone, Fentanyl, Methadone, Oxycodone Morphine (IV) 10 mg= 30 mg (PO) Hydromorphone (IV) 1.5 mg= 7.5mg (PO)

Other drugs for Parkinson Disease

Amantadine: blocks dopamine reuptake into presynaptic neurons & increases dopamine release form presynaptic fibers; used to tx dyskinesia's associated with peak dose of Carbidopa/Levodopa Selective MAO-B inhibitors: block the breakdown of dopamine which increase dopaminergic activity, primarily used as adjunctive tx to Carbidopa/Levodopa -Selegiline: can be activating, do not take at bedtime -Rasagiline has indication for monotherapy Contraindication: with other MAOi, Linezolid, Opioids, SNRIs, TCAs, Severe hepatic: Xadago; Serotonin syndrome, hypertension Centrally acting anticholinergic & antihistamine effects. Benztropine- primarily used for tremors, avoid in elderly

Select drugs that cause renal disease

Amber And Candys CKD Renal Test Looks Not Very Pleasant o AMGs, Amphotericin B, Cisplatin, Cyclosporin's, Radiographic contrast dye, Tacrolimus, Loop diuretics, NSAIDs, Vancomycin, Polymyxins ACE Inhibitors and ARBs in chronic kidney disease First-line to prevent progression of CKD when albuminuria is present -GFR <60 & or Albuminuria (AER >=30) indicates = CKD

IBD Drug Notes

Aminosalicylates: -Mesalamine ER: Induction oral therapy (6-8wks & or rectal therapy for 3-6 wks); retain @least 1-3h suppost -CI: hypersensitivity to salicylates, Note-ghost tabs -Sulfasalazine Thiopurines: immunosuppressive drugs -Azathioprine (Azasan/Imuran): tabs or injections -Mercaptopurine Warning: Genetic deficiency of thiopurine methyltransferase (TPMT) are @ risk myelosuppression -Consider genetic testing; ADEs: rash, ↑LFTs, N/V/D Integrin Receptor Antagonist: monoclonal ab -Used for induction & maintenance remission who have responded inadequately -Natalizumab (Tysabri): Injection*approved for CD/MS -Every 4 wks , DC if no response @12wks -BB: PML (opportunistic viral infection of brain) -REMs touch prescribing program -Vedolizumab (Entyvio): injection - CD & UC -DC if no benefit by 14 weeks

Motion Sickness Treatment

Anticholinergics Scopolamine (Transderm Scop): 1 patch behind the ear & take less frequently (lasts 3 days); if longer-new one o Apply at least 4 hours before needed or the night before surgery o ADEs: Dry mouth, CNS effects, stinging of the eyes, pupil dilation, IOP, remove patch before MRI DO NOT DRIVE (SEDATION) Antihistamines: Dramamine, Meclizine Drowsiness, Anticholinergic. Promethazine should NOT be used in children <2 Non-Drug: Sea Band, Ginger (Nausea) --5HT-3 RA and Metoclopramide not effective

Acetaminophen Overdose/COX1& COX2 nonselective NSAIDs

Antidote: Acetylcysteine (NAC, Acetadote) -Restores hepatic glutathione, administered IV or orally (using the soln for inhalation or injectable formulation) -Rumack Matthew Nonogram: asses levels NSAIDs: Do not use NSAIDs 3rd trimester of pregnancy -NSAIDs can prematurely close DA; MEDGUIDE -IV NSAIDs (Indomethacin, Ibuprofen) can be used within 14 days of birth to close the patent ductus arteriosus (PDA) Non-Aspirin NSAIDs: COX1 & COX2 nonselective; all have GI risk, CV risk, & risk in post operative CABG -Ibuprofen (Motrin/Caldolor/Advil): 200-400 mg q4-6 Max: OTC 1.2g; Rx: 3200g/d; ADEs: Dyspepsia, Abdominal pain, Nausea; OTC limit to <10days -Indocin: high risk for CNS ADEs (avoid in psych pts) -Naproxen (Aleve) + Esomeprazole (Vimovo): BID -Ketorolac (Toradol): Nasal 5 days, prime 5x; Warning= bleeding, acute renal failure, liver pain

Drug formulations

Apple sauce* open & sprinkle -Adderall XR, Coreg CR, Dexilant, Focalin XR, Namenda XR, Nexium, Ritalin LA Others: Singular granules, in 5 ml baby formula or breast milk or in spoonful of applesauce, carrots, rice, or ice cream Osmotic Release Oral System (OROS) -Concerta, Cardura XL, Procardia XL- use OROS to provide fast drug delivery, followed by an extended release in one drug (ghost tablets) Lidoderm patch- you can cut Remove before MRI? if contains metal -Clonidine (Catapres), Diclofenac, Estrogen, Rotigotine, Scopolamine (Transderm scop), Testosterone (Androderm)

Treatment of Conjunctivitis By Type

Blepharitis (Eyelid inflammation): warm compress & water plus baby shampoo Why do eye drops burn? Preservatives= Benzalkonium Chloride (BAK), lenses removed before eyedrops & put back after 15 min; Cosopt PF- PF free Inflamed eyes: cold compress & NSAID eye drops for mild/vs Steroids for severe Dryness: Refresh, Systane Chronic Dry Eye: Restasis Redness: Naphazoline, Tetrahydrozoline (Visine)

Allergy tx: (Moderate/Severe)

Chronic Mod/Severe-Intranasal corticosteroid -Budesonide (Rhinocort Allergy); Beconase/Qnasl -Fluticasone (both children's & adult) -Triamcinolone (Nasocort Allergy) *Budesonide & Beclomethasone= preferred in pregnancy Oral Decongestants: Phenylephrine/Sudafed PE; Pseudoephedrine/ Sudafed D -Do not use within 14 days of MAOi -Avoid in children <2 years, <4yo (package insert) -Caution in CVD, BPH Intranasal decongestant: Oxymetazoline/Afrin -NTE >3 days= Rhinitis Medicamentosa Restricted sales: Pseudoephedrine, phenylpropanolamine, and ephedrine -These products must be kept behind the counter -Max amount 3.6 g/day and 9g/mo Other: Intranasal Cromolyn= regular use; safe in children & pregnancy Ipratropium Bromide= rhinorrhea (causes dryness) Montelukast/Singulair: used in children Sublingual immunotherapy/Inj: RX EpiPen, 1st dose at doctor's office, monitor 30 min

Air quality and cleaning (compounding)

Cleaning Daily: All sterile work Daily: For HDs: Daily (Deactivate 2% bleach or peroxide/Decontamination , Cleaning (germicidal detergent, quat, ammonium, phenolics), Disinfection (Sterile 70% isopropyl alcohol) Weekly: walls, windows, bins, carts, chairs Monthly: Ceiling ISO 5 PECs, all types are cleaned often *Before each shift, Every 30 minutes while working, Before & after each batch of CSPs, Whenever needed, including after spills

Cold Vs Allergies

Cold: -Sneezing, Runny nose, Think dark mucus, Sore throat, Body aches *Symptoms take about 3 days to appear & usually last about a week Allergy: -Sneezing, Runny nose, Thin clear mucus, Wheezing, Red watery eyes *Symptoms can last for days or months after contact with allergen Nasal Irrigation & Wetting Agents -Safe in pregnancy & children (reduce stuffiness)

Common drugs that cause vision changes/ Otitis Externa/Earwax

Common drugs: look at pic Otitis Externa: Ciprofloxacin & Dexamethasone Ear wax: Carbamide Peroxide (Debrox), Triethanolamine Counseling: All eyedrops -May cause stinging except PF -Wait 5 min in between two drops of same med -Wait 5-10 min in between drops of 2 different meds -Apply gel last: wait 10 min after the last eye drop before use -Remove contact lenses prior to using eyedrops & wait 15 min for reinsert

Complications of CKD

Complications of chronic kidney disease Increase PO4 TX: Dietary phosphate restriction Phosphate binders (Ca, Al, Al/Ca free): Prior to meals Aluminum Hydroxide: rarely used due to toxicity (4wks only); TID with meals, ADEs dialysis dementia Calcium Based: first line use with Vitamin D Al free, Ca free (no accumulation, less hypercalcemia,$ -Sucroferric oxyhydroxide, Ferric Citrate, Lanthum Carbonate= TID, N/V/D, iron absorption occurs with ferric citrate Sevelamer (Renelva); non Ca, non Al based phosphate binder that is not systemically absorbed, lowers LDL Decreased vitamin D and Calcium Decreased erythropoietin (hormone that makes RBCs) Drugs that increase K -ACE-I/ARBs, Aldosterone RA, Aliskiren, Canagliflozin, Drospirenone COCs, Sulfa/Trim, Transplant drugs (cyclosporine, everolimus, tacrolimus)

PEDs- Over the counter/Virus tx

-Aspirin & Salicylates: Reye's syndrome= do not use in <16yo -Acetaminophen drops & suspension: same conct -Avoid Ibuprofen in <6mo old= risk for nephrotoxicity -Intestinal Gas: Simethicone drops 6-8mo -Nasal congestion: Humidifie, gentle suction & saline drops; FDA does not recommend OTC cough & cold in children <2 yo -Constipation: Polyethylene Glycol, Prunes, Glycerin suppositories; 2yo or older -Diarrhea: Oral rehydration solutions, such as Pedialyte & Enfamil Enfalyte -Respiratory Syncytial Virus: bronchitis/supportive care, tx inhaled Ribavirin (Virazole) RSV Px: Palivizumab (Synagis)- prevention of serious lower respiratory tract disease; only used the 1st yr of life; 1) Premature infants <29wks, Premature infants <32wks with chronic long disease, Infants <12 mo with heart condition's

When to perform hand hygiene

-Before entering & after leaving pt room -Before donning & after removing gloves -Before handling invasive devices -After coughing or sneezing -Before handling food & oral meds Use soap & water (not alcohol) -Before eating -After using the restroom -Anytime there is visible soil -After caring for pt with Diarrhea or C diff or spore forming organism -Before caring for pt with food allergy

High Alert Medications

-Can be used safely by developing protocols or order sets for use=using premixed products, limiting concentrations available & stocking high alert medications only in the pharmacy Example) Insulin: If U-500 is stocked, specify conditions under which it is used, which products will be stocked (vials & U500 syringes vs Pens), how doses will be supplied -Standardize all insulin infusions to one concentration *Do NOT place insulin in automated dispensing cabinets; all insulin orders should be reviewed by a pharmacist prior to dispensing Potassium Chloride: Remove all KCl vials form floor stock, all KCL infusions prepared in the pharmacy -Use premixed containers, Use protocols for KCL delivery which indications for IV administration, max rate infusion, max allowable concentration -Allow for automatic substitution of oral KCL for IV -Label all fluids with K = "Potassium Added"

IBD: Crohn's Disease

-Characterized by deep, transmural (thru the bowel wall) inflammation that can affect any part of the GI tract; fistulas, non continuous Crohn's Disease: Tx Induction of Remission: Steroids +- (Thiopurine or MTX) Anti-TNF, Ustekinumab (Stelara) Maintenance: · Mild: Budesonide <= 3mo- after Thiopurine or MTX · Moderate: o Anti-TNF agents: Adalimumab (Humira), Infliximab (Remicade), Certolizumab (Cimzia) o Thiopurine (Azathioprine, Mercaptopurine) o MTX o IL Receptor Antagonist: Ustekinumab (Stelera) Refractory to above tx &/or steroid dependent · Integrin Receptor Antagonist o Vedolizumab, Natalizumab

IBD: Ulcerative Colitis

-Characterized by mucosal inflammation confined to the rectum & colon with superficial ulcerations. -Distal Disease: limited to descending colon & rectum *can be treated with topical rectal tx -Inflammation limited to rectum is call proctitis Ulcerative Colitis: TX Induction of Remission: 5-ASA+- steroids (oral or rectal) · Anti-TNF, Ustekinumab (Stelara), Tofacitinib (Xeljanz), Vedolizumab, IV Cyclosporine Maintenance: · Mild: Mesalamine (5-ASA) Rectal and/oral preferred · Moderate: Anti-TNF agents Adalimumab (Humira), Infliximab (Remicade), Golimumab (Simponi) o Thiopurine (Azathioprine, Mercaptopurine) o Cyclosporine o IL Receptor Antagonist: Ustekinumab (Stelera) o Janus kinase inhibitor- Tofacitinib (not 1st line) Refractory to above tx:· Integrin Receptor Antagonist Vedolizumab

Antidotes cont...

Isoniazid: B6 Pyroxidine Iron & Aluminum: Deferoxamine (Desferal) MTX: Leucovorin (folinic acid) Neostigmine/Pyridostigmine: Pralidoxime Nicotine: supportive care, atropine, benzo Salicylates: Sodium bicarbonate, increase excretion Stimulant overdose: Benzo TCAs: sodium bicarb to decrease QRS complex Valproic acid/Topiramate induced hyperammonemia: Levocarnitine (Carnitor) Organophosphate Overdose: Tx=Pralidoxime (Protopam): reactivates cholinesterase Atropine: blocks the effects of Ach, Duodote-combination of atropine & pralidoxime Salvation Lacrimation Urination Defecation Causes: Pesticides (ppl at farms at risk)

Hypothyroidism Treatment/Pregnancy

Levothyroxine (T4): Full replacement dose= 1.6 mcg/kg/day (IBW); therapeutic eq- orange book; if know CAD start with 12.5-25 mcg/daily -Monitoring: TSH levels q 4-6 weeks until normal then 4-6months, Highly protein bound; take with water & 60 min before breakfast or at bedtime (3 hrs after meal) IV: PO 0.75-1 Thyroid Desiccated UPS (T3 & T4): Armour Thyroid Liothyronine (T3)/Cytomel: shorter half lie/fluctuations Look at pic for conversions** Lots of DDIs! Pregnancy: Levothyroxine safe & recommended (30-50% increase in dose)

Thyroid Storm

Life threatening: Fever (>103), Tachycardia, Tachypnea, Dehydration, Profuse sweating, Agitation, Delirium, Psychosis, Coma Tx: Anti thyroid PTU is preferred (>=1hr before Iodide) PLUS....... Inorganic Iodide SSKI 5 drops or Lugol's Soln Beta blockers (Propranolol) Systemic Steroids (Dexamethasone) PLUS........ -Aggressive cooling with Tylenol & cooling blankets -Supportive tx

GERD algorithm

Lifestyle modifications Initial tx (PPI once daily for 8wks)- can increase 2x/daily Maintenance tx (PPIs at lowest effective dose) Infrequent heart burn <2x/week= Antacids; Ca containing products-preferred in pregnancy -Calcium Carbonate (Constipation) +Magnesium (Mylanta) -Magnesium Hydroxide: loose stools -Sodium bicarbonate/Aspirin/Citric Acid= Alka Seltzer

GOLD Guidelines for COPD

Long term monotherapy with oral steroids or inhaled corticosteroids is not recommended -An ICS can be added to LABA or LAMA+LABA in select patients with past exacerbations & high eosinophils counts -Less common tx for severe cases- Azithromycin 5-10 days, Roflumilast , and theophylline which is not recommended

Specialty references by topics

Loot at pic

Allergy tx (Mild/Intermittent)

Mild/Intermittent -Oral/Nasal Antihistamines -Oral: little effect on nasal congestion First generation: Diphenhydramine, Chlorpheniramine, Doxylamine-Warning: elderly, Prostate enlargement, Glaucoma, lactating women Second Generation: Cetirizine & Levocetirizine = fast onset & more sedating; Loratadine & Cetirizine= best pregnancy ; less sedating=Allegra & Claritin Intranasal antihistamines: Azelastine/Astelin/Astepro; Olopatadine/Patanase

Miscellaneous Antidepressants

Mirtazapine (Rameron): central alpha 2 adrenergic antagonist which results in increase of NE -Increases sleep & appetite, weight gain Trazadone: 5HT, blocks H1 & Alpha 1 receptors -Sleep, do not use MAOI, Linezolid, IV methylene blue, Priapism Nefazodone: Inhibits 5HT & NE reuptake, blocks 5HT2 & alpha 1 adrenergic receptors -Hepatotoxicity Treatment resistant depression: does not respond to 2 trials- rule out bipolar Antipsychotics: Aripiprazole (Abilify)- insomnia, anxiety Olanzapine/Fluoxetine (Symbyax), Quetiapine (Seroquel): ALL BB in elderly pts with dementia related psychosis NMDA Receptor Antagonist: Esketamine - nasal *REMS, must be administered under supervision

Modifying Drugs in CKD & Drugs that are CI in CKD

Modifying Drug Therapy: COAG Cardiovascular drugs (bleeding): LMWHs (enoxaparin), Rivaroxaban Others: Bisphosphonates, Lithium Anti-infectives: -AMGs: nephrotoxic -Beta Lactams: seizures -Fluconazole -Quinolones (except Moxi: not cleared renally)-seizures -Vancomycin (know)- nephrotoxic Gastrointestinal drugs: H2RAs (CNS), Metoclopramide (EPS) Drugs that are CI in kidney disease CrCl <60 ml/min: Nitrofurantoin CrCl <50 ml/min: TDF containing products- if starting then <70, Voriconazole IV CrCl <30 ml/min: TAF, NSAIDs, Dabigatran, Rivaroxaban GFR <30 ml/min: SGLT2I, Metformin Other: Meperidine (seizures)

Step tx for COPD

Muscarinic Antagonist: Bronchodilation by blocking the constricting action of acetylcholine M3 muscarinic receptors in bronchial smooth muscle SAMA -Ipratropium Bromide (Atrovent HFA): MDI - 2 inhalation QID; Do not have to shake, prime 2x, close eyes so no medication gets into eyes, clean wkly -Ipratropium + Albuterol (Combivent Respimat): MDI LAMA -Tiotropium Spiriva HandiHaler: DPI: 1 capsule via HandiHaler device daily (requires 2 puffs) *HandiHaler & Neohaler devices come with capsules -Spiriva Respimat: MDI 2 inhalations daily Warning- use in caution in pts with narrow angle glaucoma, MGravis, urinary retention -ADEs: Dry mouth, upper respiratory tract infections -Monitoring: Smoking, COPD questionnaires, annual spirometry Respimat products: TOP -Albuterol/Ipratropium (Combivent Resp) -Olodaterol (Striverdi Respimat) -Olodaterol/Tiotropium (Stiolto Respimat) Turn the clear base Open the can & close your lips around mouth Press the dose release button & inhale -To clean: damp cloth

Cold tx- age/dosing

Cough: cough suppressant; Congestion: Expectorant D: Decongestant PE: Phenylephrine DM: Dextromethorphan AC: Codeine Do not use in children: Children <12: Codeine (FDA); <18 tonsillectomy Children <6: Avoid all OTC cough & cold (AAP) Children <4: Avoid many OTC cough & cold (package labeling) Children <2: Avoid OTC cough & cold (FDA), Promethazine (FDA), Topical menthol& camphor (package labeling) Dosing o Tylenol: 10-15 mg/kg q 4-6 h NTE 5 doses/24h Infant/Child Drops: 160 mg/5ml o Ibuprofen: 5-10 mg/kg q 6-8 h NTE 40mg.kg.day Infant Drops: 50 mg/1.25ml Children's Liquid: 100mg/5ml

MS Treatment

Disease Modifying Therapies: Interferon Beta Formulations & Glatiramer Acetate; MS PEGylated Interferon Beta allows for more convenient SC dosing every 14 days Glatiramer Acetate (Copaxone): Immune modulator thought to induce & activate T-Lymphocyte suppressor cells in relapsing form of MS; fridge then room temp for 30 days -Warning: chest pain, ADE-Injection site rx, flushing, diaphoresis, dyspnea, preferred in pregnancy Interferon Beta- alter expression & response to surface antigens, enhancing immune cell function; some formulations contain albumin Warning- psychiatric disorders, injection necrosis, LFTs, Flu like symptoms; do not expel air bubble Monoclonal antibody: Natalizumab- binds to alpha 4 integrins= PML, REMS TOUCH

Cold

Natural Products: Zinc- Start within 48h then q2h once awake, NTE >5-7 days (copper deficiency) Vitamin C, Echinacea Expectorants: Guaifenesin: Mucolytic (thins mucus) Ex) Mucinex, Robitussin; +Dextro= Robafen DM Cough suppressant: o Dextromethorphan (DM): 5 HT+ NDMA, >18 YO; Max dose 120mg/d; serotonin syndrome if used with others o Codeine: CII - by itself CV- Combo CI <12 yo (not indicated <18 yo), CYP2D6 metabolism Caution: respiratory depression , o Benzonatate (Tessalon Perles): Stretch receptors centrally (stop feeling), Avoid <10 yo o Diphenhydramine: Similar to Dextromethorphan · Other tx: o Decongestants, Analgesics/Antipyretics, Combo products

Motion Sickness

Nausea: Uncomfortable, queasy feeling that one may vomit Tx: The chemoreceptor trigger zone (CTZ) in the CNS contains receptors for Dopamine (DA), Serotonin (5HT) & Acetylcholine (Ach)- each receptor can set off a chemical pathway leading to nausea & vomiting. -Blocking the receptors reduces nausea -Blocking 5 HT with 5 HT3 receptor antagonist (Ondansetron) -Blocking DA with Phenothiazine (Prochlorperazine) -Blocking 5HT & DA with metoclopramide (prokinetic that moves food through the gut) Vertigo: Dizziness with the sensation that the environment is moving or spinning. Typically due to inner ear condition that affects balance Tx: Vestibular (inner ear) Suppressants- including antihistamine (Meclizine, Dimenhydrinate) & Benzos -5HT3 receptor antagonist are not useful for vertigo because they do not affect the inner ear Motion Sickness: dizziness, with a sensation of being off balance and woozy due to repetitive motions, such as boat moving over waves or an airplane flying in turbulent weather Tx: Anticholinergics (Scopolamine) & Antihistamines

Pediatric Conditions Age Classification/Screenings

Neonate: 0-28 days Infant: 1 month-12 months Child: 1-12 years Adolescent: 13-18 When to seek urgent care or symptoms do not improve Age < 3 mo: Temperature 100.4 (rectal Age 3-6mo: Temperature 101/38.3C (rectal) Age >6mo: Temperature 103 F (rectal) -After birth: screened for phenylketonuria & CF; give IM VK to prevent bleeding -Patent Ductus Arteriosus: NSAIDs such as IV indomethacin or ibuprofen given to close PDA (14days) -Respiratory Distress Syndrome: tx with surfactants; <35wks; "Surf" or "actant" ex) Curosurf

IBD (inflammatory bowel disease)

IBD: Inflammatory conditions of the colon & small intestine; blood diarrhea, flares, remission -Major types: Ulcerative Colitis & Crohn's Disease IBS (Irritable Bowel Syndrome): doe not cause inflammation Oral steroids: Prednisone (Deltasone) Budesonide (Entacort-for CD only , Uceris- UC only) Rectal steroids: UC ONLY Hydrocortisone (Cortenema, Cortifoam) Budesonide rectal foam (Uceris)

Other COPD tx

-For Beta 2 agonist look at Asthma Phosphodiesterase 4 inhibitors -Roflumilast (Daliresp): Contraindicated- mod/severe liver impairment, ADEs-Diarrhea, weight loss Aclidinium (Tudorza Pressair): hold the inhaler with mouthpiece facing you & green button straight up, press- dose is ready if changed from red to green, breath until you hear click, do not hold down green button while breath, remove & breath out thru nose, control window now red, to clean wipe Ellipta products: Fluticasone (Arnuity Ellipta), Fluticasone/Vilanterol (Breo), Umeclidinium (Incruse), Umeclidinium/Vilanterol (Anoro) Neohaler products: Glycopyrrolate (Seebri Neohaler), Glycopyrrolate/Indacaterol (Utibron Neohaler), Indacaterol (Arcapta Neohaler) "click on the side"

Compounding Personal Staff Training

-Initial/Continuous Training Required training & testing for STERILE compounding -Hand hygiene, Garbing & gloving technique, cleaning & disinfecting procedures for sterile space & equipment, Sterile drug preparations Gloved finger tip test: initially the annually (if only compounding in low-medium risk, Semi annually (High) -Incubated for 2-3 days, colony forming units (CFUs)= contamination was present; require 3 fingertip samples with zero CFUs both hands Media fill test: determine if compounder is preparing CSPs in an Aseptic manner, turbidity (cloudiness- contamination is present (after 14 days)

Pharmacogenomic Testing

Abacabir (Ziagen): HLA-B*5701 -Risk for rxns, if Positive= do NOT use Allopurinol (Zyloprim, Aloprim): HLA-B*5801; -Increased risk for SJS; if Positive= do NOT use Carbamazepine (Tegretol), Oxcarbazepine (Trileptal), Phenytoin (Dilantin), Fosphenytoin (Cerebyx): HLA-B*1502- SJS & toxic epidermal necrolysis (TEN); test in all Asian pts before starting Carbamazepine; If Positive= do NOT use Clopidogrel (Plavix): CYP2C19; is a prodrug, pts with CYP2C19*2 or *3 alleles are poor metabolizers -Consider alternative Codeine: CYP2D6; prodrug metabolized to morphine. Ultra rapid metabolizers due to extensive conversion= overdose; If known= do NOT use Warfarin (Coumadin, Jantoven): CYP2C9*2 & *3, VKORC1; Increased bleeding; start with lower dose Trastuzumab (Herceptin): HER2; these drugs are HER2 inhibitors, if tumor HER2 negative= drugs not effective! Cetuximab (Erbitux): KRAS mutation; -if Positive for KRAS= do NOT use Azathioprine (Azasan/Imuran): TPMT, If TPMT activity is low/absent= start at very low dose or use alternative tx Capecitabine (Xeloda), Fluorouracil: DPD deficiency= increased risk of severe toxicity (diarrhea, neutropenia, neurotoxicity); if DPD deficient= do NOT use

Alzheimer's disease (AD): Treatment

Acetylcholinesterase Inhibitors: inhibit centrally active acetylcholinesterase, the enzyme responsible for hydrolysis (breakdown of acetylcholine; this causes increase in acetylcholine Donepezil (Aricept): 5 mg QHS (nausea); diarrhea -Warning: Cardiac (brady cardia), QT prolongation Rivastigmine (Exelon): patch/capsule; Patch & Donepezil ODT have less GI symptoms -If stable on Donepezil 10mg can switch to Namzaric NMDA blocker-inhibits glutamate from binding & decrease neuron activation Memantine (Namenda): ADEs- dizziness, confusion, headache, constipation Namzaric (Namenda+Donepezil): do not crush or chew, Capsules can be sprinkled on apple sauce ***Caution with other drugs that cause low HR, drugs that have anticholinergic effects reduce efficacy

Common skin conditions

Acne Treatment: OTC Benzoyl peroxide (can bleach hair) & salicylic acid, retinoids, topical or systemic abx & systemic isotretinoin Warning: Retinoids Teratogenic, use pea size amount -Takes 4-12 weeks to work, cholesterol & pregnancy test -Spironolactone, Azelaic Acid (acne & rosacea) Cold Sore: OTC Abreva/Docosanol, RX acyclovir topical, Oral antivirals Dandruff: Ketoconazole shampoo, selenium sulfide, pyrithione zinc (head & shoulders), Coaltar shampoos Alopecia: Finasteride (Propecia), Minoxidil topical Eyelash: Bimatoprost (Latisse) Eczema (Atopic dermatitis): -OTC: Petrolatum, Lanolin (Aquaphor, Eucerin, Keri) -RX: 1st) Steroids 2nd) if steroids failed-Topical CNIs- associated with lymphoma, Topical Phosphodiesterase- 4 inhibitor (Crisaborole/Eucrisa), Monoclonal Antibody (IL-4 antagonist)-Depulimub Hyperhidrosis: OTC (antiperspirants), - RX (Glycopyrronium topical-Qbrexza) Fungal infections: -OTC: Terbinafine (Lamisil AT Cream), Butenafine (Lotrimin Ultra Cream), Clotrimazole, Miconazole (Lotrimin AF), Tolnaftate (Tinactin), Undecylenic Acid (Fungi nail) -RX: Betamethasone/Clotrimazole (Lotrisone), Ketoconazole Cream Onychomycosis (Nail): Oral + Topical = Moderate/Severe: Itraconazole & Terbinafine Vaginal Fungal Infection: pregnancy= complicated (7-10 days) OTC, Topical: Clotrimazole (Gyne-Lotrimin), Miconazole (Monistat 3) -RX, Topical: Butoconazole (Gynazole-1), Terconazole -RX, Oral: Fluconazole (Diflucan): 150 mg PO x 1 Diaper Rash: Clotrimazole, Miconazole, Nystatin for stubborn rashes if yeast is involved -OTC: Petrolatum/Zinc Oxide (Desitin, Butt Paste, Triple Paste) -RX: Miconazole+ Zinc Oxide+ Petrolatum (Vusion) -Hemorrhoids: Phenylephrine (Preparation H Topical) & Hydrocortisone (Anusol HC Supp) -Pinworm (Vermicularis): OTC: Pyrantel Pamoate (Reese's Worm) RX: Albendazole (Albenza), Mebendazole (Emverm)- CNS Toxicity=Often given with steroids or AEDs Lice: Permethrin (NIX), Pyrethrin/Piperonyl Butoxide (RID) Scabies: Permethrin cream (Elimite), Ivermectin Oral (Stromectol) Bites/Cuts/Burns: OTC: Neosporin - Triple ABX (Polymixin|Bacitracin|Neomycin Rx: Mupirocin (Bactroban)-good staph & strep coverage;Bacitracin/Neomycin/PolymyxcinB/Hydrocortisone (Cortisporin ointment) Poison Ivy, Oak & Sumac: Aluminum Acetate *is a astringent, Colloidol Oatmeal (Aveeno), Topical or Oral steroids, Cold compress Inflammation & Rash: Topical steroids; OTC: Hydrocortisone 0.5% and 1%;All other steroids RX § Potency from highest to weakest § oint>creams>lotions>solns>gel>sprays

Traditional (Non biologic Disease Modifying Drugs

Articular Symptoms of RA -Joint swelling, Pain, Stiffness, Bone deformity, Weakness, Difficult to move, Edema, Redness TX: should be started on DMARD= slow the progression -MTX is preferred initial tx; never use combo biologics Check FILE for med info*** Traditional (Non biologic Disease Modifying Drugs MTX: never dose daily for RA (liver damage); folate give to decrease hematological, GI/Hepatic ADEs; don't take with alcohol, NSAIDs, Sulfonamides/Tacrolimus *Rasuvo & Otrexup single use auto injection -Administer SC into abdomen, upper thigh only** Hydroxychloroquine (Plaquenil): Irreversible retinopathy, eye exam Sulfasalazine (Azulfidine): CI in pts with sulfa & salicylate allergy; can cause yellow/orange skin/urine Leflunomide: inhibits pyrimidine synthesis; Do NOT use in pregnancy, hepatotoxicity, 2 yrs to get pregnant JAK: inhibit JAK enzyme which stimulate immune cell function; "nibs" -BB: serious infection (TB),Malignancy, Thrombosis

Migraine Diagnosis /Acute OTC tx

At least 5 attacks 1) Headache lasts 4-72 hrs & recur sporadically 2) Headaches have >=2 of the following: unilateral location, pulsating, moderate-severe pain & aggravated by routine physical activity 3) One of the following occurs during the headache: Nausea/Vomiting, Photophobia (sensitivity to light) and phonophobia (sensitivity to sound) Acute abortive tx: headache that is already present -OTC acetaminophen, Advil Migraine (only ibuprofen), Excedrin Migraine (Aspirin, Acetaminophen, Caffeine), Aleve (Naproxen) --Rebound headaches: limit acute tx 2-3x/week

Dopamine Replacement Drugs & Agonists

Carbidopa/Levodopa (Sinemet, Sinemet CR): Levodopa is a precursor of dopamine, Carbidopa inhibits Dopa decarboxylase enzyme, preventing peripheral metabolism of levodopa -CR 25 mg/100mg PO TID, CR tab can be cut in half -CI: Nonselective MAOi within 14 days -ADEs: Nausea, Dizziness, Orthostasis, Dyskinesia's, Hallucinations, Psychosis, dark/black urine, Coombs test- discontinue drug, sexual urge, priapism Note: 70-100 mg/day of Carbidopa required COMT inhibitors: increase the duration of action of levodopa; inhibits the enzyme COMT to prevent peripheral conversion of Levodopa: 200 mg/dose -Entacapone (Comtan): only w Levodopa use Dopamine Agonist: act similar to dopamine Pramipexole (Mirapex): Warning- daytime sleep attacks, hallucinations, dyskinesia Ropinirole (Requip XL) Rotigotine (Neupro): application site rxns, once daily, do not use same site for 14 days, remove MRI Dopamine Agonist Injection for advanced disease: Rescue movement drug for "off periods": -Apomorphine (Apokyn) Injection: Dose written in mL, must be started with test dose at doctors CI- Do not use with 5HT3 antagonist, severe hypotension, loss of consciousness -ADEs: Severe nausea/vomiting, hypotension

Depression causes & diagnosis

Causes: Neurotransmitters include 5HT, Glutamate, Acetylcholine, Dopamine, NE, Epinephrine Diagnosis: DSM-5 Criteria At least 5 of the following symptoms during the same 2 week period (must include depressed mood or diminished interest/pleasure); M SIG CAPS Mood-Depressed Sleep-Increased/decreased Interest/Pleasure-Diminished Guilt or feeling of worthlessness Energy-decreased Concentration-decreased Appetite-increased/decreased Psychomotor agitation or retardation Suicidal ideation * When depression & anxiety occur together- BZDs should not be used alone (they worsen or mask depression); risk for physiological dependence, withdrawal symptoms, respiratory depression, & death

Emergency Preparedness, Toxicology & Antidotes

Decontamination with activated charcoal: Used in specific types of orally ingested drugs; need to be given within 1 hour of ingestion- Contraindicated: when airway is unprotected= is unconscious, cannot clear their throat, cannot hold head up Additional Antidotes: Anticholinergic: Physostigmine Anticoagulants: Warfarin-Phytonadione (VK), KCentra -Heparin/LMWH= Protamine, Dabigatran (Idarucizumab/Praxbind), Apixaban/Riv=Andexxa Benzo: Flumazenil- can cause seizure BB: glucagon; CCB: calcium Cyanide/Nitroprusside: hydroxocobalamin Digoxin: Digoxin immune Fab (DabiFab) Ethanol: B1 Thiamine 5 FU/Capecitabine: Uridine Triacetate (Vistogard, Xuriden)

Drugs for tx of Secondary Hyperparathyroidism

Elevations in PTH are treated with Vitamin D Vitamin D3 (Cholecalciferol): ultra violet light Vitamin D2 (Ergocalciferol): Dietary source Calcimimetic (Cinacalcet/Sensipar): increase sensitivity of calcium sensing receptor on the parathyroid gland which causes decrease in PTH, Ca, & PO4

Emergency Contraceptives/Extra counseling points/Infertility

Emergency Plan B: Levonorgestrel with in 72h, no age restrictions -Preventing ovulation/thickens cervical mucus, Nausea -Less effective if over 165lbs Ulipristal (Ella): less effective if over 195lbs, up to 5days -Requires RX, not abortion pill, delays ovulation Paragard IUD: within 5 days, by doctor 99.9% effective Counseling: COCs: increase blood clots risk, ADEs- nausea, weight gain, breast tenderness, side effects improve after 3 mo, Taking the pill with food or at night helps with nausea Contraceptive patch: apply to dry clean skin-buttocks, upper arm, or upper torso Infertility: not being able to get pregnant after 1yr -Clomiphene is first line: SERM which act as estrogen agonist in some tissues & estrogen antagonist in other ADEs: hot flashes, has clotting risk -Increases LH/FSH= ovulation (release of eggs) -Gonadotropins

Contraception & Infertility

Fertility awareness: LH surge; ovulation kids predict best time for intercourse Pregnancy: Human Chorionic Gonadotropin (hCG) is released when a fertilized egg attaches Preconception health: Take folic acid (400mcg/day) to help birth defects, stop smoking/drinking, vaccinations are current, avoid hazardous drug list (NIOSH) Hormonal Contraceptives: work by inhibiting FSH & LH, which inhibits ovulation

Systemic Steroids

Fludrocortisone mimics Aldosterone (water & electro) -FDA approved for Addison's disease Steroid Dose Equivalence: Cute Hot Pharmacist & Physician Marry Together & Deliver Babies C: 25mg H: 20 mg P: 5 mg P: 5 mg M: 4 mg T: 4 mg D: 0.75mg B: 0.6 mg Person is immunosuppressed if: >= 2 mg/kg/day or >=20 mg/day of prednisone for >2wks Use of strong immunosuppressants can increase the risk of certain conditions: -Reactivation of TB & Hep B/C, testing must be done px, Viruses, Lymphomas, Infections

Common Adjuvants for Pain Management

Gabapentin (Neurontin)/Horizant for PHN &RLS -Dizziness, somnolence, peripheral edam/wt gain Pregabalin (Lyrica): CV: approved for fibromyalgia, PHN, neuropathic pain associated with diabetes Carbamazepine (Tegretol): Only approved for Trigeminal Neuralgia Antispasmodics: use caution with CNS depressants Baclofen (Lioresal): all muscle relaxants= sedation, confusion, muscle weakness Cyclobenzaprine (Amrix, Flexeril): dry mouth Tizanidine (Zanaflex): hypotension, dry mouth Antispasmodics- exert their effects by sedation Carisoprodol (Soma): C-IV poor CYP2C19 metabolizers= will have increase concentrations Methocarbamol (Robaxin): sedation

Infection during pregnancy

Generally considered safe to use: penicillin (including amoxicillin & ampicillin), cephalosporins, erythromycin & azithromycin Vaginal fungal infections: Topical antifungals (cream, suppositories) x 7 days Urinary tract infections: Cephalexin 500 mg PO Q6H x 7 day Ampicillin 500 mg PO Q6H x 7 day -Nitrofurantoin & Bactrim should be considered LAST line during 1st trimester, & should not be used in the last 2 weeks of pregnancy -MUST TX BACTERIURIA even if asymptomatic Toxoplasmosis - avoid dirty food products, cat feces -Avoid Fluconazole Lactation: avoid amphetamines, amiodarone, ergotamine's lithium, metronidazole, phenobarbital, and statins

Heparin- High alert med

Require programmable pumps Sentinel event= results in death

Migraine: Causes

Imbalances in neurotransmitters such as Serotonin - A decrease in neurotransmitter causes vasodilation in cranial blood vessels Natural Migraine products: · Migraines Really Can Cause Bad Fever o Mg, Riboflavin, CQ10, Caffeine, Butterbur, Feverfew Avoid triggers (See picture) Menstrual Associated Migraine (MAM): tx with oral contraceptives, patch, or creams to decrease frequency; Monophasic -Migraine with Aura AVOID estrogen containing products

Drugs associated with severe skin rxns/Anaphylaxis tx

Severe Skin Rxns: -Abacavir, Allopurinol, Carbamazepine, Ethosuximide, Lamotrigine, Modafinil, Nevirapine, Penicillin, Phenytoin, Sulfa Anaphylaxis Tx: -Immediate emergency, call 911 -Tx epinephrine injection +- Diphenhydramine=-Steroids+-IV fluids -Epi pen: can be administered through clothing, ok if there is still fluid in it, 2nd dose may be given, massage area for 10s after injection Aztreonam safe in pts with Penicillin allergy Otitis Media: allergy to penicillin/amoxicillin give Cefdinir, Cefpodoxime, Ceftriaxone or Cefuroxime Peanuts & Soy: Avoid Clevidipine, Propofol, Progesterone Eggs: Avoid Clevidipine, Propofol, Yellow fever -For influenza : use Flublok

Ergotamine Drugs, Butalbital drugs: Migraine

Nonselective agonist of serotonin receptor, which causes cerebral vasoconstriction- use if CI to triptans or no benefits with triptans Dihydroergotamine (DHE 45, Migranal): IM/SC/IV, Or Nasal spray= PRIME 4x Ergotamine + Caffeine (Cafergot, Migergot) BB: CI with CYP3A4 inhibitors due to ischemia, uncontrolled hypertension, pregnancy Butalbital -Containing products= not recommended -Fioricet (acetaminophen, butalbital, caffeine) -Fiorinal (aspirin, butalbital, caffeine)= C-III

Nonsterile Compounding Sterile Compounding Hazardous Drugs

Nonsterile Compounding: cannot be commercially available; used to change the formulation such as solid to liquid to help pt swallow better or adding flavors -Separated from dispensing part of room, powder containment hood (Ventilated Compounding Enclosure); water sinks (both tap & distilled) Sterile Compounding: strict procedures, free from contamination, Non hazardous IV drugs, Hazardous IV, Radiopharmaceuticals, Irrigations, Eyedrops -Must include ante room, buffer area & PEC or SCA Hazardous Drugs: Antineoplastic, Non neoplastic (hormones, immunosuppressants)= men & women with reproductive capability must confirm in writing they understand the risks -CPEC (C is for containment) & SPEC: required to keep HD particles, vapors contained within the space due to toxicity risk = negative air flow -Closed front PECs do not need to be placed inside a PEC

Color Drug References

Orange (FDA): List of approved drugs that can be interchanged with generics based on therapeutic equivalence Pink (CDC): Information on epidemiology & vaccine preventable disease Pink Sheet (Pharma Intelligence): News report on regulatory, legislative, legal & business developments Purple (FDA) biologics/biosimilars Green (FDA): Information on approved animal drug products Red: Drug pricing Red, Pediatrics (AAP): summaries of pediatric infectious disease, antimicrobial tx & vaccinations Yellow (CDC): Information on the health risks of international travel, required vaccines & prophylaxis meds

Parkinson's Disease Symptoms/Drugs that make it worse

PD: Neurological Disorder which usually develops after the age of 65. The cells that produce dopamine (DA) allows smooth, coordinated function of the body muscles & movements; when 80% of dopamine are damaged motor symptoms appear T R A P major symptoms: Tremor- when resting, Rigidity- in legs, arms, trunk Akinesia/Bradykinesia-lack of slow start in movement Postural Instability- imbalance, falls Dopamine blocking drugs that worsen PD -Phenothiazines (Prochlorperazine) used for psychosis, nausea, agitation -Butyrophenones (Haloperidol, Droperidol) used for psychosis -First/Second generation antipsychotics (Risperidone at higher doses, paliperidone); lowest risk Quetiapine -Clozapine has low risk of movement disorders but high risk of agranulocytosis, seizures -Metoclopramide, renally cleared drug that can accumulate in elderly patients

PCA pump

Patient controlled analgesic administered intravenously with a machine: allow patient to treat quickly-will not let pt take more than ordered -They can be complex & require set up, pts should have cognitive assessment prior to use -Family & friends should not administer PCA= TJC requirement -Limit the opioid available in floor stock; use stander order sets -Educate staff about HYDROmorphone & Morphine mix up -Implement PCA protocols that include independent double checking of the drug, pump setting -Use barcode technology -Asses the patient's pain, sedation, & RR

Alzheimer's disease

Symptoms: -Memory loss, getting lost -Difficulty communicating, repeating words & info -Inability to learn or remember new information -Difficulty with planning & organization -Poor coordination & motor function -Personality changes, Inappropriate behavior -Paranoia, agitation, hallucinations Drugs that can worsen dementia -Antiemetics, Antihistamines, Antipsychotics, Barbiturates, Benzo, Central anticholinergics (Benztropine), Peripheral anticholinergics (IBS drugs), Skeletal muscle relaxants, CNS depressants Supplements for memory: Ginkgo Biloba, Vitamin E (bleeding risk)

Malaria Prophylaxis and Treatment

Prophylaxis: initiated 1-2 days prior to travel -Atovaquone/Proguanil -Doxycycline (Doryx/Vibramycin): photosensitivity -Primaquine: do not use G6PD deficiency ALL: daily, avoid in pregnancy, Nausea-take w food Advanced starts 1-2 weeks prior to travel -Chloroquine: stop 4 weeks after travel -Mefloquine: do not use underlying psychiatrics conditions, seizures, arrhythmias -Tafenoquine: do not use in G6PD deficiency ALL: weekly regimens, safe in children, pregnancy, choice depends on resistance in the region

Glaucoma Treatment

Prostaglandin Analogs: increase aqueous humor outflow; 1 drop QHS Bimatoprost (Lumigan)/Latisse=eyelash growth, Latanoprost (Xalatan, Xelpros)- refrigerated Travoprost (Travatan Z): ADEs- darkening of iris, eyelashes, length & number can increase, blurred vision, stinging, increase pigmentation Beta Blockers: reduce aqueous humor production -All nonselective except (betaxolol): burning, stinging, bradycardia, bronchospasm TImolol: 1 drop daily or BID Timolol+ Dorzolamide (Cosopt PF) Cholinergic: Increase aqueous humor outflow -Carbachol, Pilocarpine; ADEs poor vision at night due to pupil constriction Carbonic Anhydrase Inhibitors: reduce aqueous humor production-Timolol+ Dorzolamide (Cosopt PF) Adrenergic Alpha 2 Agonist: increases aqueous humor outflow, reduces aqueous humor production Rho kinase inhibitors: increase outflow

Renal disease

Proximal Convoluted Tubule: regulates PH, SGLT2i -GFR (Metformin, SGLT2i) Loop of Henle: Loop diuretics (inhibit Na-K), electrolyte losses (calcium) DCT: thiazides (inhibits Na-Cl); increase calcium, Aldosterone Collecting ducts: AldosteroneS

TCAs/Dopamine & NE Reuptake Inhibitors/MAOi

TCAs: inhibit NE, 5HT- they also block ACh & histamine receptors Tertiary Amines: Amitriptyline (Elavil), Doxepin Secondary: Nortriptyline CI: Do not use with MAOi, Linezolid, IV methylene blue Cardiotoxicity-QT prolongation with overdose, orthostasis; dry mouth, blurred vision, urinary retention, constipation, weight gain Bupropion: same CI as above MAOi: inhibit monoamine oxidase which breaks down catecholamines (5HT, NE, Epi, DA)- hypertensive crisis Isocarboxazid (Marplan), Phenelzine (Nardil) Tranylcypromaine (Parnate), Selegiline transdermal patch; do not consume tyramine rich foods (yeast, air dried meats, aged cheese, sauerkraut) MAOi Tip GAL: keep them separated; 2 week washout- SSRIs, SNRIs, TCAs, Bupropion 5 week washout- Fluoxetine (Due to long half life)

Raynaud's phenomenon/Celiac Disease/Myasthenia Gravis

Raynaud's Phenomenon -Common condition causes by cold/stress leading to vasospasm in the extremities (fingers & toes) -Decrease in blood flow to fingers causes increase in cyanosis (blue fingers) & pain -White due to lack of blood flow, Blue as vessels dilate to try to keep blood in tissues, Red as blood flows Tx: CCB= Nifedipine , PDE5i, topical nitroglycerin Drugs that make it worse: BB, Bleomycin, Cisplatin Celiac Disease -Symptoms: Diarrhea, abdominal pain, bloating, weigh loss= Tx avoid gluten such as corn, potato, wheat Myasthenia Gravis -Attacks connections between nerves & muscles= weakness in eyes, face, neck, & limbs TX: Cholinesterase inhibitors= block breakdown of acetylcholine which improves neuromuscular transmission & increases muscle strength -Pyridostigmine: cholinergic effects

Treatment for Severe Hyperkalemia

SEE PIC Notes: -Patiromer: not for acute or emergency use -Hemodialysis: removes K from the blood -Sodium Polystyrine Sulfonate (SPS Kayexalate): Warning electrolyte disturbances, can bind other oral meds

SSRIs/SNRIs- Depression

SSRIs: increase bleeding risk with anticoagulants Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac)- Sarafem for Premenstrual dysphoric disorder, Paroxetine (Paxil)-Brisdelle for mod/severe vasomotor symptoms of menopause , Sertraline- preferred in pts with cardiac risk, Fluvoxamine -CI: do not use with MAOi, Linezolid, IV methylene blue Warnings: QT prolongation, Citalopram NTE 20mg/day in elderly & Escitalopram NTE 10mg/day in elderly, SIADH/hyponatremia, fall risk, bleeding ADEs: decrease libido, somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, headache -Sedating: Paroxetine; Fluoxetine-activating SNRIs: Venlafaxine (Effexor XR): Depression generalized anxiety disorders, panic disorder, social anxiety Duloxetine (Cymbalta): Depression, peripheral neuropathy, Fibromyalgia, GAD, chronic muscle pain -ADEs due to NE: increased heart rate, dilated pupils, dry mouth, excessive sweating, constipation Desvenlafaxine (Pristiq)

Select drugs that cause or worsen depression/Safety concerns

Select drugs that cause or worsen depression ADHD medication: Atomoxetine Analgesics: Indomethacin Antivirals (NNRTIs): Efavirenz (Atripla), Rilpivirine Cardiovascular: Beta blockers (Propranolol) Hormones: Hormonal contraceptives, Anabolic steroids Other: Antidepressants, Benzo, Systemic steroids, Interferons, Varenicline, Ethanol Natural products used for depression: -St. John's wort, (SAMe) or Valerian Safety concerns: Oral nonselective monoamine oxidase inhibitors (MAOi) such as phenelzine, tranylcypromine & isocarboxazid are restricted Taper- all except fluoxetine since it has a long half life Depression & Pregnancy - Should assess risk vs benefit: Paroxetine cause pulmonary hypertension in newborns -Postpartum: SSRIs or TCAs except doxepin MEDGUIDES- required (black box- suicidal ideation)

Supplements

Supplements safety is the manufacturer's responsibility which should be proven prior to release- cannot claim to treat cure or lessen conditions Four areas of concern: DDIs, increase bleeding, cardiotoxicity, or hepatotoxicity Supplements that increase bleeding: 5 Gs -Garlic, Ginger, Ginkgo, Ginseng, Glucosamine -Fish oils (higher doses), Vitamin E, Dong Quai, Willow Bark (Salicylate) Inflammation: Omega 3, Flax/seed/Turmeric Folate Acid (Folate): all women of child bearing age should obtain 400mcg/day of folic acid. During pregnancy increases to 600 mcg/day; should be taken at least 1 month before pregnancy Iron: breastfed babies need 1mg/kg/day from 4-6mo old and until consuming iron rich foods Vitamin D: exclusively breast fed babies drinking less than 1 L of baby formula =400 IU of vitamin D

Types of Surfactants

Wetting agents: reduce the surface tension with liquid & solid to allow the substance to spread easily Emulsifiers: 2 or more liquids which are not able to blend together Suspending agents: Solids dispersed in a liquid Levigating/Trituration: grind down particles (mineral oil-lipophilic or propylene glycol for aqueous)