MU NURS 615: Advanced Pharm - Exam 4 Review

What is tiotropium?

(Spiriva) Tiotropium bromide (INN) is a long-standing, 24 hour, anticholinergic bronchodilator used in the management of chronic obstructive pulmonary disease, (COPD).

What is the Step Up Approach with GERD?

1-antacids, lifestyle, & OTC antacids H2RAs and -PPI (if no erosive disease present) 4-8 weeks if better- back to H2, if worse continue if not better -refer out

What ethnic background should not be prescribed long-acting beta agonists?

African Americans, increased incidence of death in this population

What inhibits the secretions of the nose, mouth, pharynx, and bronchi and thus causes dryness of the mucous membranes of the respiratory tract.

Atropine

What is the mechanism of action of inhaled muscarinic receptor antagonist?

Atropine (the prototype of muscarinic receptor antagonists) prevents the effects of ACh by competitively blocking its binding to muscarinic receptors in the CNS, peripheral ganglia, and at neuroeffector sites on smooth muscle, cardiac muscle, and secretory glands.

Histamine and bradykinin

Atropine also partially antagonizes bronchoconstriction induced by ___ and ___.

Methacholine

Atropine is effective against bronchoconstriction induced by parasympathomimetic drugs like ______.

Neuromuscular junction.

Because muscarinic receptor antagonist cause little blockade of the effects of ACh at nicotinic receptor sites, extremely high doses of atropine or related drugs are required to produce any degree of blockade of the predominantly nicotinic receptors at the ___ ____.

What is tiotropium used for maintenance treatment of?

COPD, which includes chronic bronchitis and emphysema.

What special population should not be administered bismuth subsalicylate?

Children and adolescents should not be administered this during or after recovery from chickenpox or flu-like illness. also not for anyone with ASA hypersensitivity.

What drug should be prescribed for patient with nasal congestion with hypertension?

Coricidin HBP

What medications are considered antitussives?

Dextromethorphan, Codeine, Benzonatate; (examples include: Scot-Tussen DM, Hold DM, Robitussin, Vicks, Delsym, and generic

What is the mechanism of action of the different classes of diuretics?

Diuretics lower BP by deleting the body of sodium and reducing extracellular fluid volume.

What are the adverse effects of antihistamines?

Drying effects: dry mouth, difficulty urinating, constipation, changes in vision, mild drowsiness to deep sleep, increased heart rate, motor-impairment, flushed skin, photosensitivity, itching skin, increased body temp, nausea or vomiting.

What is the mechanism of action of inhaled corticosteroids?

Extremely potent vasoconstrictive and anti-inflammatory activity.

How will you choose a diuretic in the treatment of HTN?

First check the level of kidney function, thiazide diuretics need GFR > mid 40's. Check BUN and creatinine.

How will you treat nausea and vomiting?

First-line therapy is Vit B6 and Unisom, especially in pregnant women. Ginger is helpful. Zofran, especially in children.

Bismuth subsalicylate is used to reduce the chance of ulcers from what?

H. pylori

What is the mechanism of action of the phenothiazine antiemetics?

Has strong anticholinergic effects; blocks histamine-1 (reduces exocrine gland secretions) block dopamine receptors in the chemoreceptor trigger zone (CTZ). They also bind to and block cholinergic, alpha 1 -adrengeric, and histamine receptors.

What medication would you prescribe for bronchospasm for a patient taking propranolol?

Ipratropium

What are the adverse effects of bismuth subsalicylate?

It can cause rebound constipation; gray/black stools and black tongue (does not indicate GI bleeding).

How does metoclopramide improve GERD

It increases tone and amplitude of gastric contractions and relaxes the pyloric sphincter & duodenal bulb, and increases peristalsis of the duodenum and jejunum resulting in accelerated gastric emptying and increase speed of gastric transit. Works on the dopamine receptors.

What is the mechanism of action of ondanestron?

It is a 5-HT3 receptor antagonist and blocks serontonin both peripherally on vagal nerve terminals and centrally in the CTZ (chemoreceptor trigger zone).

When should bismuth subsalicylate be administered?

It is indicated in the use of Traveler's diarrhea d/t its antidiarrheal and antisecretory properties. It should be given for up to 4 times/day for up to 3 weeks after each loose stool up to maximum daily dose.

Why is osteoporosis a risk when taking omeprazole

It is not clear how PPIs might increase fx risk, but it may be that by inhibiting stomach acid, PPIs speed up bone mineral loss. Bone fx d/t lose of calcium

What patient teaching should accompany the prescription of montelukast (Singulair)?

It will not work fast enough to treat an asthma attack that has already begun. Use only a fast-acting inhalation medicine to treat an asthma attack.

What lab values should be monitored with long-term administration of proton pump inhibitors?

LFTs, H & H, B12, Ca++, bone-density monitoring for patients with osteoporosis.

What can be administered if bulk is ineffective for children?

Lactulose 7.5ml qd.

What patient education should be provided to the patient taking antacids?

May cause constipation or diarrhea

How will you treat constipation in children?

Miralax is first line tx. Bulk form laxatives are the safest and produces physiologic effect similar to increasing fiber in the diet. Bulk forming are used for management of chronic diarrhea in adults.

What are the contraindications to the use of misoprostol?

Must be used cautiously in pts with renal compromise, Pregnancy Category X, most likely should not be given to nursing mothers, and no one under 18 years of age.

What special populations should not be prescribed pseudoephedrine?

Not to be used in children under four years of age, and patients with HTN.

What is the first line therapy for peptic ulcer disease with a positive H pylorus?

PPI 2x daily, amoxicillin 1 g 2x daily, and clarithromycin 500mg 2x daily for 7 to 14 days. Triple line therapy and continue PPI for 8 to 12 weeks until healing is completed.

What is the second line therapy for those who fail treatment initially?

PPI 2x daily, metronidazole, tetracycline, and bismuth salicylate for 14 days. Quadruple therapy. Tx may fail d/t microbial resistance

What conditions should cause a patient to avoid the use of antihistamines?

Patients over 60 or under 6 years of age; elderly, antihistamines are contraindicated for nursing mothers, newborns, and premature infants.

Patients with what disease should consult their doctor before taking antihistamines?

Patients with thyroid disease, HTN, heart disease, kidney disease, liver disease, asthma, chronic bronchitis, emphysema, difficult urination, or glaucoma. Men with BPH.

What is the mechanism of action of potassium-sparing diuretics?

Potassium-sparing diuretics are competitive antagonists that either compete with aldosterone for intracellular cytoplasmic receptor sites, or directly block sodium channels (specifically epithelial sodium channels (ENaC ) by amiloride)

What is the mechanism of action of albuterol?

Relaxes bronchial smooth muscle by action on beta 2 receptors with little effect on heart rate, causing dilation of airways.

When is it appropriate to use a short acting beta agonist?

Short acting beta 2 agonist (SABAs) are the drug of choice for acute treatment of asthma symptoms and exacerbations.

What are the adverse effects of montelukast (Singulair)?

Side effects of Singular can include skin rash, mood changes, tremors, h/a, stomach pain, heartburn, upset stomach, nausea, diarrhea, tooth pain, tiredness, fever, stuffy nose, sore throat, cough, and hoarseness. Singular may interact with phenobarbital or rifampin.

What is an example of an epithelial sodium channel blocker?

Spironolactone

What is the Step Down Approach with GERD?

Start with lifestyle modifications and PPI for 8 weeks. If s/sx free for 4 weeks, step down to H2RA. If s/sx not relieved, increase PPI to BID for 4-8 weeks. If s/sx free for 4 weeks, step down to daily PPI, and reassess in 6-12 months. If s/sx not relieved refer patient out for an endoscopy.

What are some safe ways to get relief from URI symptoms?

Steam inhalation and gargling with salt water

What is the most rapid acting laxative and why?

Stimulants d/t the direct action on intestinal mucosa by stimulating the mesenteric plexus. The also facilitate the release of prostaglandins and increase cAMP concentration, thus increase electrolyte concentration and stimulate peristalsis.

What is the mechanism of action of proton pump inhibitors?

The PPI binds irreversibly to a hydrogen/potassium ATPase enzyme (proton pump) on gastric parietal cells and blocks the secretion of hydrogen ions, which combine with chloride ions in the stomach lumen to form gastric acid.

What is the mechanism of action of codeine in the suppression of cough?

The physiological mechanism of cough is complex, and little is known about the specific mechanism of action of the opioid antitussive drugs. It is likely that both central and peripheral effects may play a role. It works as a CNS depressant. Works on the cough center of the brain in the medulla oblongata.

What is the mechanism of action of docusate sodium?

They reduce the surface tension of the oil-water interface on the stool and facilitate admixture of fat and water into the stool, producing and emollient action.

What patient teaching should be provided when prescribing inhaled corticosteroids?

They should be taken 2x a day every day for the use of prevention of asthma. Rinse mouth after use to prevent oral thrush.

What are the adverse effects associated with inhaled corticosteroids?

Thrush, dysphonia, cough, and bronchospasm, thin skin, bone loss, smell of burning plastic, h/a, and visual changes

How are upper respiratory infections treated?

____ are mostly treated for relief of symptoms. Some people benefit from the use of cough suspressants, expectorants, vit C, and zinc to reduce s/sx or shorten the duration.

What is used to treat fever, aches and pains with URIs?

analgesics such as APAP and NSAIDs

Singulair can lead to what mood changes?

anxiety, depression, or thoughts of suicide or of hurting yourself

Singulair should not be used for exercised- induced

bronchoconstriction

What enzymes are inhibited by carbonic anhydrase inhibitors?

carbonic anhydrase found in the proximal convoluted tubule. This results in several effects including bicarbonate accumulation in the urine and decreased sodium absorption.

PPIs reduce gastric acids levels by more than 90% and frequently produce this?

hypochlorydria.

Tiotropium

is a muscarinic receptor antagonist, often referred to as an antimuscarinic or anticholingeric agent.

Tiotropium

is not used in the treatment for acute exacerbations of COPD and bronchitis

What are the disadvantages of using stimulant laxatives for prolonged periods of time?

long-term use of stimulant laxatives can lead to loss of colon function (cathartic colon).

Which diuretics promote calcium excretion?

loop diuretics whereas thiazide diuretics do not

What are two examples of osmotic diuretics?

mannitol and isosorbide.

Patients taking long-term proton pump inhibitors are at risk for developing what?

megablastic anemia; hip fractures and osteoporosis

Loop and thiazide-type diuretics both increase the excretion of what?

potassium

Nasal decongestants can improve breathing. But the treatment may become less effective with repeated use and can cause what?

rebound nasal congestion

What is the fasted acting stimulant laxative?

rectal administration of bisacodyl laxative

Patients taking what medications should consult their doctor before taking antihistamines?

sedatives, sleeping pills, or muscle relaxants.

What increase parallel with inhibition of the acid secretion with PPI use, lasting for up to 72 hours after each dose?

serum gastrin levels.

What is the action of loperamide?

slows gastric motility and diminishes the loss of fluid and electrolytes

Atropine

the depression of mucous secretion and the inhibition of mucociliary clearance is an undesirable side effect of ___ in patients with airway disease.

Atropine and scopolamine

the inhibition of secretions is esp marked if secretions is excessive and is the basis for the use of which drugs in preanesthetic medication.

What uses high osmotic and solute gradient to transport solutes and water?

the loop of Henle

What is effected after decades of frequent use of stimulant laxatives?

the nerves of the colon slowly disappear, the colon muscles wither, and the colon becomes dilated. Consequently, constipation may become increasingly worse and unresponsive to laxatives.

What are the mechanism of action of thiazide-type diuretics?

they act on the distal renal tubule to inhibit sodium reabsorption, their effect is usually longer lasting and with less brisk diuresis. They decrease preload thereby decreasing blood pressure.

What are epithelial sodium channel blockers (ENaC)?

they are sodium channel blockers that are selective for the epithelial sodium channel. They prevent the production of proteins that are normally synthesized in reaction to aldosterone. These mediator proteins are not produced, and so stimulation of sodium-potassium exchange sites in the collection tubule does not occur. This prevents sodium re-absorption and potassium and hydrogen ion secretion.

Osmotic diuretics can also act at other parts of the body. What are some examples of their other actions?

they can be used to reduce intracranial and intra-ocular pressure.

How do osmotic diuretics work?

they expand extracellular fluid and plasma volume, therefore increasing blood flow to the kidney. This washes out the cortical medullary gradient in the kidney, and stops the loop of Henle from concentrating urine.

What effect does osmotic diuretics have on blood and nephrons?

they increase the osmolarity of blood and renal filtrate. In the nephron, osmotic diuretics act at the portions of the nephron that are water-permeable.

What is the mechanism of action of osmotic diuretics?

they inhibit reabsorption of water and sodium (Na). They are pharmacologically inert substances that are given intravenously.

What are the mechanism of action of loop diuretics?

they inhibit sodium reabsorption in the ascending loop of Henle. They are short-acting and cause a large natriuresis. Sodium stays with the water in the tubule and both are voided.

What are the mechanism of action of agents that act in the RAAS?

they reduce pressure by decreasing sodium and water retention (aldosterone action), and by increasing vasoconstriction (angiotensin direct action) and by increasing vasodilation (bradykinin action)

What is the mechanism of action of calcium sparing diuretics?

they reduce the amount of calcium excreted into the urine and can increase the serum calcium levels, which may be beneficial in patients with hypocalcemia.