Pharm Final New material:

Here is the study guide for the new material for the final. I don’t have time to do a concise version of the old material, but here is a combined word doc of all the previous study guides so it is easily searchable.

pharmstudyguidefull

NewMaterial

New Material:

 

estrogen-progesterone combined hormone therapy

 

  • together there is a lower chance of endometrial cancer
  • Monophasic—fixed ratio of estrogen and progestin that is taken for 21 days
  • Biphasic—supplies 2 different amounts of progestin during the first and second phases of the menstrual cycle
  • Triphasic—dose of estrogen is constant while progestin is progressively increased (three times) for 21 days

 

anthelmintics

  • A class of antiparasitic drugs that expels parasites from the body.
  • Niclosamide (Nicolicide)
    • Use against flatworms.
    • stool sample must be negative for the parasite for three months to be “cured”
    • Action: kills the head (scolex)
    • parasite is digested once killed.
  • Piperazine
    • paralyzes the worm, then it detaches and is excreted.
  • Mebendazole (Vermox)
    • vermacicidial
    • increased absorption w/ fatty food.

estrogen hormone replacement therapy

  • increase synthesis of DNA, and proteins.
  • can cause Na retention and lower cholesterol
  • For estrogen deficiency, osteoporosis prevention and health
  • SE: WEIGHT GAIN, changes in menses pattern
  • gain about 5lbs of weight from the medication.
  • cautions: endometrial cancer with use over 2 years, do not give to breast feeding women, effects liver, clotting(MI, Stroke), bladder stones,
  • contraindications: breast cancer, abnormal vaginal bleeding, Thrombophlebitis, PE, hyperCa, endometriosis
  • smoking can increase cardiac issues and chance of stroke.

antifungals

 

  • Amphotericin B
  • Broad spectrum  

 

      • Cell wall/membrane permeability is disrupted
        • humans have cell membranes…
        • binds -sterols which are also found in the human body (cholesterol) which causes the renal damage.
        • it is very toxic
      • used for SYSTEMIC mycoses that are potentially fatal, admin parenteral: infusion reaction fever and chills, nephrotoxic
      • ADME: can be found up to a year later in the pt body

 

  • Griseofulvin
  • still in the -azole class
  • just for SUPERFICIAL  (skin infections), not systemic
  • inhibits fungal mitosis

 

    • s/e: Insomnia, Rash and headache

 

  • Ketoconazole

 

    • used in less severe fungal reactions (fungistatic)
    • MOA is it inhibits the synthesis of ergosterol which is a part of the fungal cell membrane
      • this also affects the body’s sterols (sex hormones)
    • -conazols are all less toxic

 

  • Mycostatin (Nystatin)

 

    • Candidiasis only
    • It is in the form of a mouth wash
    • alters the permeability of the membrane
    • used for infant thrush often due to the low side effects.

 

Premarin (estrogen)

  • conjugated estrogen
  • from HORSES
  • see estrogen for SE and other info

anti-parasitics

 

  • for malaria:

 

    • Mefloquine
      • No photosensitivity
      • once a week dose
      • can be used w/ kiddos
      • There are serious psychological SE: anxiety, hallucinations
  • for amebiasis
    • Metronidazole (flagyl)
        • for invasive amebiasis, giardiasis, trichomoniasis
        • SE: neurotoxic, Disulfiram reaction, be cautious with anticoagulants, thrombophlebitis, furry tongue?

oral contraceptives (OCPs, BCPs)

  • Newer OCP have less of the hormones and less side effects.
  • Heavier people have a lower % of “coverage” because of the increased body weight
  • inhibit FSH and LH release
  • many SE and increased coagulability, weight gain, cramps, acne or less acne,
  • Can help with anemia by lessening blood loss during periods.

IUDs

  • a T shaped piece with a copper coil that is pressed up against the fundis and prevents pregnancy for about 5 years.

topical glucocorticoids

Ring / Patch

  • NuvaRing
    • insert for 3 wk
    • take out after menses
    • higher risk of clot than PO

 

  • Patches
    • change wkly, three in a box
    • do not put on the breast
    • Higher risk of clot than PO

isotretinoin (Accutane)

  • Anti acne
  • Preg X
  • monitor triglycerides
  • Steven johnson syndrome, Suicide, Necrolysis, severe birth defects.

Estrogen only pills

  • these are for estrogen replacement, secondary for bone health, and vaginal atrophy
  • Estradiol and estrone are natural occurring steroidal estrogens
  • Conjugated estrogen (Premarin)
  • Diethylstilbestrol (DES) is synthetic
  • Transdermal estrogen (Estraderm)
  • Vaginal creams
  • Compounded mixtures

doxycycline (Tetracycline)

 

  • Broad spectrum
  • Inhibit protein synthesis
  • Effective through PO route
  • for ACNE, lyme Dx, H. pylori, Cholera, Rickettsia, cholera
  • Can treat MRSA with Clindamycin, and Bactrim

 

  • chelation occurs when calcium, Iron, and magnesium containing supplements and foods inactivate the tetracycline and cause it to be inactive
    • do not take with meals!
    • one hour before or two hours after meals to avoid chelation
  • S/E: photosensitivity, brown teeth, not ok for mothers pregnant and breastfeeding moms, do not give to kiddos.

 

testosterone

  • schedule II drug
  • useful for osteoporosis to increases the building blocks for bone growth
  • indicated for hypogonadism, androgen deficiency, may reverse ED, delayed male puberty.
  • administration
    • PO, IM, patches, skin gel
  • SE: ab pain, insomnia, gynecomastia, frequent erections, prostate growth, frequent urination
  • monitor

PDE-5 inhibitors

 

  • cialis
  • levitra
  • Viagra

 

    • schedule II drug
    • useful for osteoporosis to increases the building blocks for bone growth
    • indicated for hypogonadism, androgen deficiency, may reverse ED, delayed male puberty.
    • administration
      • PO, IM, patches, skin gel
    • SE: ab pain, insomnia, gynecomastia, frequent erections, prostate growth, frequent urination
    • monitor for vision changes.

ED Drugs (PDE-5 inhibitors)

 

  • Cialis
  • levitra
  • viagra

 

 

5-alpha reductase inhibitors

  • finasteride (Proscar)
    • inhibits conversion of testosterone into androgen DTH resulting in shrinkage of the prostate.
    • Indication: BPH
    • SE: decrease in lebedo and impotence.
    • Women who are pregnant or may become pregnant should not handle this drug. Male changes in genitalia may result.

DDAVP desmopressin

  • Antidiuretic hormones, for DI (deficiency of ADH) or a deficiency of Vasopressin
  • Nasal route, blow nose before administration
  • only works Neurogenic DI not Nephro-
  • so could be used after head injury and surgery
  • can be used for enuresis too which is bed wetting
  • Complications: water intoxication (imbalance of electrolytes and causes drowsiness headache convulsions and coma)
  • cardiac patients are at a high risk for s/s from fluid overload

vasopressin

  • Antidiuretic Hormone
  • for DI from too little ADH and severe vasodilated shock
  • only excrete unbound water
  • alters renal permeability to reabsorb more water.
  • Decreases urine output and increases BP.
  • can cause an MI in a person with a cardiac pathology
  • Monitor BP, HR and ECG in cardiac patients

amyl nitrate

  • For Chest pain
  • cyanide antidote

thyroid labs

    • TRH is released in the hippocampus
    • TSH is released in the pituitary
    • T3 and T4 are released in the thyroid

 

  • each of these stimulate the production of the chemical below. T3 and T4 slow production/release of TRH telling the hippocampus that there is enough T3/4.  

 

  • In hyPERthyroidism there is high T3 and T4 and low levels of TRH and TSH.
  • In hyPOthyroidism there is low T3 T4 and high levels of TRH and TSH.
    • this can be different depending on other factors, but the takeaway is that the T3/4 hormones are low in hypo and high in Hyper.

BPH Drugs

 

  • 5-alpha reductase inhibitors

 

    • finasteride (Proscar)
  • alpha blockers have an effect shrinking the prostate too

levothyroxine

  • this is T4 and gets converted by the body into T3
  • The dose is very patient dependent and there are MANY pill quantities. this also means that a Generic drug which can be plus or minus 20% of the drug, may cause the patient to be getting too much or too little of the drug.
  • Long H life of a week
  • daily dosing
  • takes about a month to get to the therapeutic effects

liothyronine (Cytomel)

 

  • T3

 

    • shorter H life
    • more money
    • faster onset

radiocontrast dye

 

  • antidote: N-acetylcysteine, Na Bicarb, and normal saline

 

pilocarpine

  • for glaucoma
  • Direct acting cholinergic agonist
  • causes meiosis and contraction of ciliary muscles.
  • eye drops 6qd

flumazenil

  • antidote for Benzos (valium, Diazepam)

cycloplegic drugs

 

  • paralyze ciliary muscles
  • SE: Blurry vision, angle-closure glaucoma, Anticholinergic effects

 

  • mydriatics – dilate the pupil, for surgery and examinations
    • Phenylephrine – dilated eye

N-acetylcysteine

 

  • Antidote for Contrast induced Nephropathy, w/ sodium bicarb and NS
  • antidote for CONTRAST DYE!!!
  • Antidote for acetaminophen (TYLENOL)
  • also a mucolytic but this may be less important.

 

  • PO 140mg/kg, then 70mg/kg q4hr
  • Action: Decreases viscosity of mucus to expectorate
  • inhaled through nebulizer
  • DX that need this are COPD and cystic fibrosis
  • Onset > 1 min Peak 5-10 min
    • Bad odor
  • side effects are runny nose, throat and lung irritation, rash and stomatitis

Sodium bicarb

    • is basic and used to maintain the pH balance

 

  • CHECK IV med compatibility, will get viscous like concrete if mixed with incompatible fluids.
  • enhances renal secretion  
  • antidote for radiocontrast dye with N-acetylcysteine

 

 

ranibizumab (Lucentis)

  • angiogenesis inhibitor
  • can improve visual acuity and reduce risk of further impairment
  • SE: inflammation of the eye, seek medical attention if: eye pain, blurry vision, discharge

antioxidants

  • can help prevent Age related macular degeneration
  • reduce cold/cough time?

medroxyprogesterone

  • a progestin
  • regulates ovulation
  • build up the endometrium for the implantation of the egg

ocular decongestants

  • decrease redness and swelling by vasoconstriction
  • only work on symptoms

Depo Provera

  • IM injection contraceptive
  • lasts three months

angiogenesis inhibitor

 

  • ranibizumab (Lucentis)

 

  • can improve visual acuity and reduce risk of further impairment
  • SE: inflammation of the eye, seek medical attention if: eye pain, blurry vision, discharge

passive vs. active immunity

  • passive immunity is through antibodies
  • active immunity is acting against an active pathogen

Floxin Otic

  • fluoroquinolone, for ear infections in this case
  • can irritate the skin
  • DD interactions w/ amiodarone, and quinidine.

Hep A and B vaccines

 

  • IM inactivated virus injection
  • A
  • Children 12 months or older, 2 doses
  • Duration: 10 years Schedule; first shot, needs booster in 6-12 months Contraindicated in patients with bleeding disorders or febrile illness
  • B

 

    • three doses
    • provides 90% protection; duration unknown
    • May produce mild SE Continue schedule even if delay
    • Most have some immunity after 2 doses.

radioactive Iodine therapy I133

  • for hyperthyroidism and thyroid cancer.  
  • emits gamma and beta particles
  • 8 day H life
  • blocks hormone synthesis
  • needs synthroid after treatment for life (hypothyroid for life)
  • destroys the thyroid gland
  • Lugol’s solution – surgery prep, thyrotoxic crisis, it is an antiseptic

when not to administer a vaccine

  • MMR: not in preg, immunocompromised; allergies to neomycin, gelatin, eggs
  • Varivax: not in preg, immunocompromised, allergies to neomycin, gelatin
  • DTaP: fever, pain
  • OPV: VAPP so use IPV
  • Hib: OK
  • Hep B: anaphylaxis to baker’s yeast; Hep A: OK
  • Influ, Pneumococcal, rotavirus, meningococcal

 

what tetanus to administer by age / circumstance

 

  • If the person has tetanus: Airway, antibiotics, td vaccine, tetanus immunoglobulin
  • DTaP < 10 y.o.; Tdap > 11-12 y.o. as booster; Td if pt has hx of seizures
  • DTap – Schedule: 5 doses; first 3 are 2 mo apart, 4th at least 6 mo after 3rd dose, then between ages 4-6 Not recommended after age 7
  • Contraindicated if previous reaction Report serious rxn: high fever, convulsions, screaming or inconsolable crying, shock

 

IPV

  • Route: SQ; inactivated whole virus
  • Schedule: requires several to reach immunity
  • Protective immune response cannot be assured in immunocompromised
  • Contains trace amounts of streptomycin, neomycin, bacitracin

 

Pharm session 14:

Last Pharm session!!!

 

Session 14

 

Estrogens

  • Estrogen
    • increase synthesis of DNA, and proteins.
    • can cause Na retention and lower cholesterol
    • For estrogen deficiency, osteoporosis prevention and health
    • SE: WEIGHT GAIN, changes in menses pattern
    • gain about 5lbs of weight from the medication.
    • cautions: endometrial cancer with use over 2 years, do not give to breast feeding women, effects liver, clotting(MI, Stroke), bladder stones,
    • contraindications: breast cancer, abnormal vaginal bleeding, Thrombophlebitis, PE, hyperCa, endometriosis
    • smoking can increase cardiac issues and chance of stroke.

 

  • Progestin (megace)
    • changes the thickness of the endometrial lining for the embryo to attach to
    • suppression of ovulation during pregnancy
    • increase appetite which is helpful in anorexia and HIV
    • For hormone imbalance, to start bleeding or stop vaginal bleeding
      • about the same dose for starting and stopping bleeding

 

Contraceptives

  • older meds had higher amounts of the hormones, which caused higher levels of side effects
  • lower dose now and based on a thin teenager, so less effective in a heavier people
  • tested originally in male beagle dogs
  • Action: inhibit FSH and LH secretion, impairs implantation, increases cervical mucus to hinder sperm.
  • SE: gallstones, acne, increased clotting, changes in menses, weight gain
  • can help with anemia but lessening vaginal bleeding.
  • protection against pregnancy if the person remembers to take it
  • Phasic – the number of times that the progestin increases from one to three (mono, bi, tri)
  • Seasonale meds are 3 months on then three months off developed for Sally Wright so that she could go to space.

 

  • YAZ is similar to aldosterone(diuretic) , higher risks of clotting, there is a link to glaucoma after taking for two years. Get your ocular changes checked.

 

non pill contraceptives

  • NuvaRing
    • insert for 3 wk
    • take out after menses
    • higher risk of clot than PO

 

  • Patches
    • change wkly, three in a box
    • do not put on the breast
    • Higher risk of clot than PO
  • long acting progestin only
    • Implanon – inserted in the arm (3-5 years)
    • Depo – Provera (IM injection every 3 months) can cause BONE LOSS
    • IUD (5 years)
    • side effects: vaginal bleeding MM pain, wt gain

 

Other

  • Low-dose progestogens
    • no estrogen and less effective,
    • for during breast feeding

 

Patient education

  • miss one tab – take one now
  • miss two – take two each of the next two days
  • miss three – stop and use a different contraceptive until period.
  • Indomethacin will close the ductus arteriosus so do not take it during pregnancy

 

Postmenopausal help

 

  • Estrogen
  • SSRI
  • Herbals do not have evidence
  • SERMs help bones but increases hot flashes.
    • Ospemifene (osphena)
  • Addyi
    • antidepressant
    • not an immediate impact take for 3 months
    • viagra for women
    • low % of benefit

 

  • can take hormone replacement for 5 years if the woman starts during menopause.

 

Testosterone

 

  • schedule II drug
  • useful for osteoporosis to increases the building blocks for bone growth
  • indicated for hypogonadism, androgen deficiency, may reverse ED, delayed male puberty.
  • administration
    • PO, IM, patches, skin gel
  • SE: ab pain, insomnia, gynecomastia, frequent erections, prostate growth, frequent urination
  • monitor

 

  • what group of HTN meds can reduce BPH
    • alpha blockers

 

many drugs lower the labido of a man

many herbals for this but none are proven.

 

  • Alprostadil (prostaglandin)
    • injection into the corpus cavernosus

 

ED drugs

  • sildenafil (Viagra)
    • action: increase cGMP levels, relaxes smooth muscle, increases blood flow to the erection
    • PO one hour before activity
    • a pilot cannot take this 6-8 hr before a flight because there are changes in color vision. cannot see runway lights correctly.
    • report blue color changes!
    • drink 2L of water a day
    • can develop dependence if taken when they do not need to.
  • Levitra
    • does not need alpha blocker meds
  • Cialis
    • works for 36 hours
    • 5mg daily, or 20mg prn
      • NOT interchangeable!!
      • can cause a heart attack if taking the 20mg daily.

 

Renal disease

 

epogen – for anemia reversal

 

Alu hydroxide(antacid), Ca acetate – to bind extra phosphate

 

calcitriol (rocaltrol) – vitamin D supplement, activated vit D

 

HyperK – arrhythmia issues, causes spiked T wave,

  • Kayexalate – cation exchange resin, binds K and takes it out of the system.
  • Given in enama form and can cause a vagal response slowing down the heart.
  • Insulin can decrease K levels

 

Diuretics – loop and osmotic to deal with fluid balance

 

Na Bicarbonate – to make the pH more basic

  • watch out for the interactions with other meds in the IV line causing the line to clot up and not be patent.
  • can hold on to water, so cardiac, pulmonary, and

 

Pharm Session 13:

Non diabetic hormones and medications

 

Pituitary

 

What is the medication that mimics Oxytocin

  • Pitocin

 

Patients taking an antidiuretic are at risk for fluid overload. What patient would be at a high risk

Posterior Pituitary

 

  • Oxytocin
    • Pitocin is used to induce labor.
  • ADH – Antidiuretic hormone
    • Diabetes insipidus
      • too little ADH
      • can be genetic or injury to pituitary
      • Low specific gravity, bp high tirst
      • Need ADH meds

 

Anterior Pituitary

 

  • DDAVP (Desmopressin)
    • Antidiuretic hormones, for DI (deficiency of ADH) or a deficiency of Vasopressin
    • Nasal route, blow nose before administration
    • only works Neurogenic DI not Nephro-
    • so could be used after head injury and surgery
    • can be used for enuresis too which is bed wetting
    • Complications: water intoxication (imbalance of electrolytes and causes drowsiness headache convulsions and coma)
    • cardiac patients are at a high risk for s/s from fluid overload
  • Vasopressin
    • Antidiuretic Hormone
    • for DI from too little ADH and severe vasodilated shock
    • only excrete unbound water
    • alters renal permeability to reabsorb more water.
    • Decreases urine output and increases BP.
    • can cause an MI in a person with a cardiac pathology
    • Monitor BP, HR and ECG in cardiac patients
  • GH
    • promotes growth of bone and MM
    • GH turns into IGF 1
    • grow tall if the person is young and still growing
    • GH deficiency – these people are normal proportions just small. (treat with GH while young)
    • Acromegaly – when there is an increase in GH after growth is over, this causes bones to grow thicker ie. hands, face, big boggy heart. Self esteem issues.
  • Octreotide (sandostatin)
    • treats acromegaly by suppressing GH release
    • SE: GI, and gallstones (decrease renal function)
    • Assess for Frequency consistency of stools and bowel sounds
    • analog of hormone somatostatin
    • also suppresses Insulin and glucagon, really slow the person down
  • Pegvisomant (somavert)
    • GH receptor antagonist (binds the GH site so that GH cannot do its job)
    • Newest drug class for GH suppression
    • Well tolerated
    • sq injection monthly after loading dose
  • Prolactin
    • Makes milk
    • suppresses ovulation, but do not use this as contraceptive

 

Thyroid medication

 

hormones made here regulate metabolism, Heart function and growth/development

Dwarfism and cretinism may result if these hormones are absent

 

thyroid hormones – TRH ->  TSH ->  T3 and T4

TSH stimulates thyroid to release T3 and T4

 

T3 – active not bound form, and can cross membranes

T4 – is bound and converts to T3 to be used. There is much more T4 than T3.

 

Goiter can come from a lot of different pathologies. Including hypo 95% or goiters and hyperthyroidism 5%

 

Hypothyroidism – T3+4 Low and TSH HIGH. Myxedema

  • liothyronine – T3 analog
  • levothyroxine – T4 analog
  • there are also natural products that are from the ground up cow thyroid

 

Hyperthyroidism – T3+4 high and TSH low. Thyrotoxicosis

  • Graves disease can cause this
  • exophthalmos
  • Too much T3+4

 

  • levothyroxine (synthroid) T4 analog
    • this is T4 and gets converted by the body into T3
    • The dose is very patient dependent and there are MANY pill quantities. this also means that a Generic drug which can be plus or minus 20% of the drug, may cause the patient to be getting too much or too little of the drug.
    • Long H life of a week
    • daily dosing
    • takes about a month to get to the therapeutic effects
  • liothyronine (Cytomel) T3
    • shorter H life
    • more money
    • faster onset

 

  • Propylthiouracil (PTU)
    • used to treat thyroid storm
    • SE: agranulocytosis (discontinue drug if too low WBC count
  • radioactive Iodine-131
    • for hyperthyroidism and thyroid cancer.  
    • emits gamma and beta particles
    • 8 day H life
    • blocks hormone synthesis
    • needs synthroid after treatment for life (hypothyroid for life)
    • destroys the thyroid gland
    • Lugol’s solution – surgery prep, thyrotoxic crisis, it is an antiseptic

 

Effective hyperthyroidism results in decrease in palpitations

 

Adrenal Gland hormones

  • inner medulla stress
  • outer cortex stress, sex and salt
  • Classes
    • Catecholamines – Epinephrine, and norepinephrine
    • corticosteroids – Glucocorticoids work on glucose (cortisol), and mineralocorticoids work on the minerals and salts such as aldosterone
    • Androgens
  • these will be for Addison’s Dx and to suppress inflammation

 

glucocorticoids aka corticosteroids (hydrocortisone, and prednisone)

  • Always taper these meds if on for more than a week
    • glu, lipid, and protein increase blood levels
    • increase glu production and decrease the cellular uptake of glu
    • DO not take for long periods
    • increases cap permeability

 

  • hydrocortisone
    • synthetic cortisol, corticosteroid
    • for adrenocortical insufficiency
    • Altered glucose metabolism at the normal dose, shown by increased GLU levels.
      • HYPERGLYCEMIA, watch closely in DM patients
    • Can cause cushing’s syndrome or adrenal suppression if too much is given
    • Taper dose once the treatment is done.

 

  • Prednisone
    • steroidal Antiinflammatory, intermediate immune modifier
    • Taper the med
    • MAKE SURE THE PATIENT knows how to taper and understand the instructions
    • will go into an adrenal crisis if they do not taper and will look like a person with cushing’s disease
    • Cushing’s Dx test – Dexamethasone suppression test
      • Dexamethasone 1 mg at 2300, the measure the plasma cortisol at 0800. if the ACTH is suppressed

 

Mineralocorticoids

 

addison’s Dx patient need replacement and it comes from extreme adrenal stress. These patients need mineral and glucocorticoids.

 

  • Fludrocortisone (florinef)
    • for addison’s Dx
    • weight gain from edema so watch I and O’s
    • monitor K, BP and NA
    • geven IM in a Addisonian Crisis

 

Pharm Test 4 study guide

 

 

OD Reversal Drugs

 

 

  • NARCAN

 

      • Opiate antidote
      • given even if there is an OD of unknown cause

 

  • Flumazenil

 

    • Antidote for benzos

 

  • Amyl Nitrate

 

    • For Chest pain
    • cyanide antidote

 

  • Ipecac

 

    • To Puke
    • mallory weiss tear from violent puking
    • vomiting like the exorcist

 

  • Atropine

 

    • to stop cholinergic effects
    • It is an anticholinergic

 

  • Charcoal

 

      • Binds med in the gut so it cannot be absorbed then is passed in the stool.
      • Powder form mixed in water and sucked through a straw to prevent reddining of the teeth.

 

  • Vitamin K

 

      • Antidote for Warfarin

 

  • Protamine Sulfate

 

    • Antidote for heparin

 

Cancer

 

Antimetabolite

 

  • 5FU (fluorouracil)
  • Pyrimidine analog (disrupts nucleic acid fxn)

 

      • IV or topical admin (topical for skin cancer and we may not need to know this)
      • Cell cycle S-phase specific, prevents thymidine production
      • bone marrow depression
      • High alert medication

 

  • MTX methotrexate
  • Folic acid analog (prevents folic acid conversion)

 

    • Sphase specific
    • PREG category X
    • High alert med
    • dose limiting bone marrow supression
    • Kills rapidly dividing cells, and causes immunosuppression
    • SE: Pulmonary fibrosis, Hepatotoxicity, nephrotoxic, Steven-Johnson’s syndrome, and aplastic anemia
    • for the pulmonary toxicity, early signs are a dry nonproductive cough
    • for SJS, assess for rash as an early sign
    • for nephrotoxicity low back and flank pain is an early sign as well as changes in urination patterns or pain.

 

Alkylating agents

alkylates DNA and binds 2 guanines together to prevent the helix from becoming unbound, therefore inhibiting replication. The dose is limited by bone marrow suppression, but can be given in a bolus.

 

  • Mustargen (mechlorethamine)

 

      • inhibits DNA and RNA protein synthesis
      • for hodgkin’s disease and malignant lymphomas.
      • Cell cycle phase nonspecific
      • Contraindicated in pregnancy
      • SE: thrombocytopenia, Leukocytopenia, Seizures
      • monitor for bleeding and bone marrow suppression
      • notify provider for sore throat, neph-toxic s/s, bruising, bleeding, red stools
      • DO not drink alcohol, or take NSAIDs, or ASPIRIN, this will increase bleeding risk

 

  • Mustard Gas

 

      • similar to the nitrogen mustards, but for warfare.

 

  • Cytoxan (cyclophosphamide)

 

    • High alert med
    • most common alkylating agent
    • cell cycle phase nonspecific
    • SE: Pulmonary fibrosis, myocardial fibrosis, hemorrhagic cystitis(increase fluid intake to 3000ml/day), leukopenia(monitor for , thrombocytopenia(monitor for bleeding), anemia.  
    • increases effects of warfarin, phenobarb and rifampin increase toxicity of this drug. Prolongs the effects of cocaine.
    • monitor for edema, crackles, cardio/resp distress, HF s/s.
    • crosses BBB

 

Antibody Anti-tumor

 

  • Doxorubicin (Adriamycin)

 

    • antitumor antibiotic
    • binds directly to DNA and stops replication
    • High alert med
    • dose limiting heart failure, and bone
    • cell cycle S phase specific
    • SE: CARDIO TOXIC, dark urine stools, palms and nails, alopecia, leukopenia,
    • monitor uric acid levels, bleeding and CBC, I’s and O’s

 

Platinum

 

  • Cisplatin

 

    • produces crosslinks in DNA and is cell cycle nonspecific
    • dose limiting kidney failure
    • metastatic, head and neck, testicular, ovarian, bladder ,lung, and colon cancer
    • tubular necrosis in the kidney, ototoxic, bone marrow suppression,  severe nausea and vomiting in the first hour after administration.
    • MOA similar to alkylating agents
    • Kidney Failure is a dose limiting factor.

 

Mitotic Inhibitors

 

  • Vincristine

 

    • prevents cell division (m-phase specific)
    • SE: peripheral neuropathy (Neurotoxic), barely and bone suppression!!
      • vinblastine causes bone marrow suppression and not peripheral neuropathy, so when used together there is not stacking of those side effects.

 

AntiHormones

 

  • Tamoxifen
  • antiestrogen

 

    • for treatment and PREVENTION of estrogen related cancers ie. breast
    • SE: causes CANCER, birth defects, vaginal discharge w/ bleeding.
    • DD: carbamazepine = rapid metabolism. and erythromycin = slowed metabolism.   

 

 

  • prednisone
  • use in high doses
  • glucocorticoids
  • toxic to lymphocytes and lymph tissues

 

 

 

  • progestin (megace)
    • For breast cancer and endometrial cancer
    • used in AIDS pt for anorexia, weight gain and stim of appetite

 

Anticoagulants

 

 

  • Aspirin

 

      • suppress platelet aggregation for the platelet’s life span through cyclooxygenase inhibition.
      • doubles bleeding time for up to seven days
      • can be used for prophylaxis of MI in men and questionable in women.
      • risk of GI hemorrhage
  • Heparin

 

      • Interrupt coag pathway in factor X and thrombin
      • prevents thrombosis, post op thrombus, and more clots forming
      • SE: HEMORRHAGE, HIT, Sensitivity reaction bc it is animal product, All kinds of bleeding (gums, bruises, petechiae, hematoma, red or black stool)
      • HIT heparin induced thrombocytopenia – antibodies develop against Heparin, and the person can NEVER GET THE DRUG AGAIN, there will also be long term bleeding issues associated with this
      • RAPID acting, and only given IV never PO or IM
      • Made from animals
      • normal aPTT is 40 seconds
      • therapeutic aPTT with heparin is 60-80 seconds
      • PROTAMINE SULFATE is the antidote
    • Lovenox
      • LMW Heparin – low molecular weight heparin
      • only stops factor X not thrombin
      • for prevention and treatment of DVT, prevents complications with unstable angina
      • do not need to check aPTT
      • never givin IM

 

  • Argatroban

 

      • direct thrombin inhibitor
      • Use this drug if the patient is experiencing HIT
        • also bivalirudin does this (monitor with ACT test)
      • monitor with aPTT
      • no reversal agent
      • expensive

 

  • Streptokinase

 

      • Thrombolytic: Dissolves clot after formation
      • stick all IV’s before giving drug
      • converts plasminogen to plasmin
      • for acute MI, pulmonary emboli, to break up a clot in a central line
      • can cause bleeding, Allergic RXN,

 

  • tPA alteplase

 

      • thrombolytic: Dissolves clot after formation
      • stick all IV’s before giving drug
      • major bleeding issues. but not as much of an allergy risk
      • very similar to streptokinase

 

  • Dabigatran (Pradaxa)

 

      • direct thrombin inhibitor
      • ORAL anti coag for stroke PT’s w/ non valvular Afib
      • very expensive,
      • bleeding problems as well

 

  • clopidogrel (Plavix)

 

      • ADP receptor antagonist
      • given with ASA sometimes, but do not take ASA
      • for PAD and CVA
      • these are contraindicated with HERBALS
      • proton pump inhibitors makes plavix not effective

 

  • Warfarin (coumadin)

 

    • indirectly decreases many clotting factors
    • works in the LIVER not the blood
    • normal tests while on warfarin are INR(2-3sec) and PT (12sec)
    • effects IIV, IX, X and prothrombin
    • for long term treatment of thrombosis, or pulmonary embolism, also prophylaxis of clot formation(TIA, Prosthetic valve, Afib)
    • Lasts much longer than heparin
    • SE: bleeding like the rest
    • keep Vit K levels consistent throughout treatment
    • Vit K is the antidote
    • d/d interactions increase clotting: quinidine, antibiotics, NSAIDs, cimetidine, thyroid hormones, ASA, Tylenol even

 

Musculoskeletal

 

 

  • Diazepam (Valium)

 

      • Centrally acting MM relaxants
      • flumazenil is the antidote for this
      • used to treat spasticity
      • CNS depression, sedation
      • benzo

 

  • Selegiline (Eldepryl)

 

    • for parkinson’s and for pt’s taking levodopa

 

 

  • Baclofen

 

      • for spasticity
      • analog for GABA
      • SE: sedation and HA, dizziness, diplopia and weakness
      • do not stop the administration of this drug suddenly
      • taper over 2 weeks or: hallucinations, fever rigidity, paranoia, seizures
      • DO NOT mix with ALCOHOL
      • given 2-3 times/day
      • herbal interactions: kava-kava, valerian root, or chamomile these can cause CNS depression
      • no antidote
    • Carbamazepine (tegretol)
      • SZ med
      • nerve pain and bipolar disorder

 

  • cyclobenzaprine (Flexeril)

 

      • Centrally acting MM relaxants
      • do not use in:hyperthyroidism, heart conduction difficulties, heart failure, recent MI.
      • urine color change
      • do not use with other SSRI’s

 

  • Metaxalone (Skelaxin)

 

      • Centrally acting MM relaxants
      • ACH effects, caution in sedation w/ elderly

 

  • methocarbamol (Robaxin)

 

      • Central acting MM relaxant
      • unknown MOA
      • for acute injuries
      • give ¾ x/day, urine color change, dizzy, drowsy, metallic taste.
      • intensifies with ETOH
      • chemically similar to tricyclic antidepressants

 

  • Tizanidine (Zanaflex)

 

      • Centrally acting MM relaxants
      • ACH effects, caution in sedation w/ elderly

 

  • NM Blocker in general
  • Bisphosphonates (alendronate)

 

      • decrease bone resorption
      • SE: esophageal irritation, Heartburn, osteonecrosis of the jaw, atypical femur fracture
      • SEVERE esophagitis, stand for 30 MINUTES after swallowing with water only
      • do not take with other drugs

 

  • Teriparatide

 

      • STIMULATES bone formation
      • SQ injection
      • can be taken for up to 2 years

 

  • NSAIDs (COX 1 and 2)

 

      • used in RA until the DMARDS kick in, (this is changing from NSAIDS to glucocorticoids though)
      • 1st line treatment for gout

 

  • DMARDs (MTX, Arava, Plaquenil)
  • Disease-modifying anti-rheumatic drugs

 

      • given first for RA
      • take glucocorticoids until DMARD’s take effect
      • suppress autoimmune inflammatory process
        • TNF is a part of the inflammatory process…

 

  • Synvisc

 

      • injectable directly into the joint
      • cartilage and synovial fluid synthesis

 

  • Indomethacin

 

    • NSAID for gout
    • inhibits prostaglandins
    • only give for 3-6  days

 

  • colchicine

 

    • older gout drug
    • stops inflammation cycle, by decreasing mobility of granulocytes
    • treats acute gout attack

 

  • Allopurinol

 

    • febuxostat (Uloric)
    • Xanthine oxidase inhibitor, stops production of uric acid
    • for chronic gout
    • Drink 3 liters of water per day

 

Diabetes Mellitus

 

Proinsulin is the prohormone to insulin, and is bound to a C-peptide. The peptide will be found in T2DM, but not T1DM.

type 1 can have Ketoacidosis (DKA), and type 2 can have Hyperosmolar hyperglycemic non ketotic state (HHNK)

 

incretins stimulate insulin release, suppresses glucagon, slows GI emptying, as well as suppress appetite.

 

prediabetes

Impaired fasting glucose (IFG) 100-125

impaired glucose tolerance (IGT) 140 – 199 two hours after the oral glucose tolerance test

6.5% > HgA1c > 5.7%

 

Diabetes Diagnosis

HgA1c > 6.5%

FBG > 126

glucose tolerance > 200

 

Insulin

(also promotes K uptake by the cells, so can also be given for hyperK)

 

  • Lantus

 

      • no peak, duration of 24 hours

 

  • Detemir

 

      • no peak, duration of 24 hours

 

  • NPH

 

      • O: 60-120 P: 6-14 D: 16-24
      • cloudy solution

 

  • 70/30

 

      • 70% NPH, 30% Regular
      • roll gently to mix

 

  • Regular

 

      • O: 30-60 min P: 1-5hr D: 6-10hr

 

  • Lispro

 

    • O: 5-10 min P: 30min-2.5hr D: 3-6.5hr

 

Orals

 

  • Biguanide (Metformin)

 

      • stops liver glucose production in liver, increases glucose uptake in the periphery skeletal muscles.
      • Will NOT cause insulin production. this means that this drug does NOT put a person at risk for hypoglycemia.
      • Can be used with regular insulin and sulfonylureas
      • SE: Renal issues from LACTIC ACIDOSIS. If a person has renal insufficiency they are put at a much higher mortality rate.
      • MONITOR renal fxn.

 

  • Sulfonylureas (glipizide, Amaryl)

 

      • First line, promotes insulin secretion,
      • SE: HYPOGLYCEMIA
      • similar structure to a sulfonamide antibiotic
      • these are 2nd gen. and have longer durations than the 1st gen and fewer d/d interactions.
      • D/D: all cause HypoGLY: ETOH, sulfonamides, Cimetidine, NSAIDs, beta blockers

 

  • Glitazones (pioglitazone)

 

      • decrease insulin resistance, and decreases liver glucose production
      • SE: HYPOGLYCEMIA
      • Not a first line med
      • D/D interactions: CIMETIDINE, ketoconazole, rifampin, Atorvastatin

 

  • Glinides

 

      • stimulates pancreatic secretion of insulin
      • SE: HYPOGLYCEMIA
      • Can be used with metformin
      • DD: Gemfibrozil

 

  • A-Glucosidase inhibitors (acarbose, miglitol)

 

      • Delays carb absorption
      • 2% of drug is absorbed orally
      • SE: abb cramps, borborygmus bowel sounds, flatulence

 

  • DPP-4 inhibitors (Sitagliptin)

 

    • Stops DPP-4 from breaking down incretin
    • the hormone Incretin increases insulin release, decreases hepatic glu production and release.
    • Few SE and DD

 

Injectable noninsulin

 

 

  • INcretin mimetics (exenatide – Byetta)

 

      • increase release of insulin, decrease glucagon secretion, makes you feel full, and slows GI emptying
      • SQ INJECTION at breakfast and supper
      • from Gila monster spit
      • Nausea and vomiting
      • Hypoglycemia possible WITH sulfonylureas
      • a new formulation is once a week SQ injection!
      • SE: weight loss

 

  • Amylin mimetics (pramlintide – Symlin)

 

    • Slows GI emptying, decrease glucagon release, pt will feel more full, decrease postprandial glucose levels
    • SE: HYPOGLYCEMIA

 

Antianemics (heme)

 

 

  • Iron sulfate

 

      • use a straw
      • toxic in kids
      • Makes RA worse
      • for iron deficiency anemia

 

  • B12

 

      • treats b12 or pernicious anemia
      • b12 is needed to synthesize folic acid for cell growth and development
      • Cyanocobalamin

 

  • Folic Acid (folate)

 

      • for folic acid anemia
      • essential for cell replication
      • anemia can be from alcoholism, liver damage.

 

  • Deferoxamine

 

      • high affinity for ferric iron
      • do not take with oj

 

  • Erythropoietin

 

    • stimulates RBC production
    • mimics a natural hormone produced in the kidney
    • needs the supplies to make RBC’s: iron, folate, and B12
    • indications: chronic renal failure, anemia from chemo, or a chronic anemic patient having surgery.
    • can cause HTN
    • if HGB increases above 11 MI, CVA, and HF chances are increased dt increased clotting

Pharmacology Session 12

Session 12

 

Diabetes

 

DM 1 – autoimmune disorder of carb, fat, and protein metabolism

DM 2 – late onset disorder of carb, fat, and protein metabolism

  • resistance to insulin, and can have decreased insulin
  • liver is breaking down glycogen into glucose because the sugar cannot get into the cells and signals are sent saying that the cells need more sugar.

 

glucagon increases blood sugar by breaking down glycogen

amylin decreases blood sugar, helps with seisity telling the brain that you are full

 

  • Proinsulin is produced by the pancreas, and medications are just in the insulin form
  • if a person does not have any c peptides that are attached to the proinsulin, then their pancreas is not creating any insulin.

 

  • Ghrelin – produced in the stomach, low levels in of this increases insulin resistance,
  • Incretins – inhibit glycogen and increase insulin
  • IFG – impaired fasting glucose
  • IGT – impaired glucose tolerance

 

criteria for DM diagnosis

  • HgA1C > or equal to 6.5%
  • FBG > 126 mg/dl (7mmol/l)

 

DM 1 has a risk of ketoacidosis

DM 2 has a risk of Hyperosmolar hyperglycemic nonketotic state

 

Any body stressor will increase blood sugar

 

long term complications

  • macrovascular DX: HTN, stroke, Heart DX
  • microvascular DX: neph, neur, retin, Gastroparesis

 

Know the patho of each class and the adverse effects.

oral

  • Metformin (glucophage)
  • Sulfon
  • Glitazones
  • Alpha Glucosidase inhibitors
  • Gliptins

Injectable

  • Incretin mimetics
  • Amylin mimetics
  • Insulins shortest to longest
    • lispro (humalog) 5-10 min onset
    • aspart (nocolog) 15-20 min onset
    • glulisine (apidra) 15 min onset
    • Regular (humulin) 30 min onset peak in 2-4 hr and duration of 6-8 hr
    • NPH neutral protamine 60, 6-8hr, 15 hr
    • Detemir, Glargine

 

Insulin admin

  • rotate injection sites to prevent lipodystrophy
    • upper arm, thigh, abdomen
  • mixing
    • draw up clear first (clear before cloudy)
      • clear is often fast acting and cloudy is often long acting)
    • don’t mix often
    • NPH can mix with anything
  • can store for 1 month at room temp and 3 months at a cooler temp

 

  • regular insulin
  • onset 60
  • peak 2-4 hr
  • duration 6-8 hr

 

  • Lispro
    • 5-10
  • NPH insulin
    • 60-120 min
    • 6-14 hr
    • 16-24 hr
    • cloudy
  • Glargine (lantus)
    • CANNOT BE MIXED
    • 24hr duration of action
    • given SQ
      • clear liquid
    • very stable
  • Combo insulin
    • roll the vial gently to mix the short acting insulin and the NPH.

 

ORAL drugs

 

 

  • Biguanide
  • Metformin, often 1st drug prescribed

 

        • inhibits glu production in liver
        • decreases insulin resistance

 

  • does not cause hypoGLU
  • can cause lactic acidosis (don’t take with alcohol or contrast dye)

 

          • stops metabolism of lactic acid resulting in metabolic acidosis
          • can be fatal in half of people
          • happens more often in pts with renal insufficiency

 

  • Sulfonamides
  • sulfonylureas (-ide)

 

        • one of the first meds
        • increase insulin release

 

  • can cause hypoGLU
  • don’t take with alcohol, NSAID, Sulfonamides, Cimetidine, Beta blockers
  • all cause hypoGLU
  • thiazolidinediones (glitazones)
  • Avandia (rosiglitazone)
  • Actos (pioglitazone)
  • can cause hypoGLU

 

  • Glinides
    • increase insulin production
    • can cause hypoGLU
  • A-glucosidase inhibitors
    • Acarbose (precose) Miglitol (Glyset)
      • works in the small intestine to delay glu absorption
      • only 2% of the drug is absorbed orally
      • S/E are all GI issues ie. flatulence, upset stomach
  • Incretin Enhancers DPP-4 inhibitors
    • sitagliptin (januvia)
      • stops breakdown of incretins, stimulates release of insulin from pancreas, decreases liver glu production
      • well tolerated
      • no DD interactions

 

Other injectables non insulin

 

  • GLP-1 agonist is an incretin mimetic
    • correction of insulin amount
    • stops liver from unneeded glu production
    • decreases absorption of glu at intestinal level

 

  • exenatide (byetta)
    • increased fullness
    • decrease glucagon
    • decrease glu production
    • increase insulin
    • decrease gi emptying
    • from gila monster spit

 

DKA happens in type 1

HHNS happens in type 2 higher glu levels than DKA.

  • no ketones in urine

 

somogyi effect – hypoGLU at night

Dawn effect – hyper GLU at night

 

Pharmacology session 11:

Cancer, Musculoskeletal, and poison:

Cancer

  • unregulated cell proliferation
  • activation of oncogenes, and inactivation of tumor suppressor genes
  • these are genetic changes

Chemotherapy

  • disseminated cells
  • interrupts mitosis during cell division
    Hair, GI tract, skin all divide fast too so most of the symptoms come from this.
  • solid tumors
    • use radiation and surgery
  • killing all of the malignant cells is almost impossible
  • dose limiting effect is when a specific amount of dose causes adverse effects that will outweigh the benefit of the drug.
  • toxicities of chemo
    • cisplatin – tubular necrosis in the kidney
    • Vincristine – Neurotoxicity – in the periphery
    • Daunorubicin – cardiac toxic HF
    • The classes are by what they kill
    • Must be certified to administer cancer drugs
    • INFILTRATION is very important!!! chunks of tissue will fall off!!!
  • Megace (progestin)
    • increases appetite
    • used in aids and anorexia
    • s/e alopecia

Hormone/ Hormone antagonists

  • anti-estrogen
    • Tamoxifen, raloxifene
  • Estrogen
    • DES
      • causes vaginal cancer decades later in the mother, daughter, granddaughter, (testicular cancer in the sons)

Musculoskeletal Drugs

muscle spasms

  • Caused by hypoCa, injury, back pain,

treatment

    • non medication first ie. ice and PT
    • Anti-inflammatories
    • CNS acting MM relaxers
      • Methocarbamol – (robaxin)
        • decreases activity and tone of muscle
        • tid-Qid
        • color of urine changes
  • MM relaxers should be short term use only
  • Drugs for spasticity
    • Baclofen (Lioresal)
    • similar to GABA
    • Causes diplopia and weakness
    • do not come off drug fast, must be tapered
      • if taken off too fast causes fever, tetanus, hallucinations
    • NO Antidote
  • NM blockers
    • block ACH from the nicotinic receptors
      • causes MM relaxation
    • Non-depol NM blocker
      • tubocurarine (curare)
        • old, used in arrows!
        • flaccid paralysis
        • not CNS action
        • works in tissues only
  • NM blocker II
    • Flaccid paralysis
    • – curinum
  • Depol neuro MM blocker
    • Succinylcholine
      • very short acting paralysis
        • for intubation
      • S/E: Malignant hyperthermia, sever MM contractions and cannot get out of the contraction, arrhythmias, Potassium release from MM
      • Can’t move but can hear and feel
      • can’t breath
      • Face recovers first, but there may be a lot of the drug still in the system

Calcium

  • normal value 8.5-10.5 mg/dl
  • absorption increased by vit D and PTH
  • hypoCa: increase twitching chvostek’s sign, rickets, convolution

osteoporosis

  • increased fragility of bone and low bone bone mass
  • can run in the family
  • prevention through Ca supplementation, weight bearing exercise, and not smoking
  • Drugs that stop resorption of bone
    • – dronates
  • drug that help build bone
    • teraperitda
  • Calcium supplements should be separated throughout the day

Paget’s disease

  • bone overgrowth, but very fragile

bisphosphonates

  • Alendronate (fosamax) -Dronate
    • inhibitor of osteoclast from breaking down bone
    • the amount of time between doses can range from weeks to a year
    • S/E: GI esophageal irritation(take an hour before other drugs and stay upright for 30 min after taking it), osteonecrosis of the jaw(loose teeth), atypical femur fracture(mid thigh)
    • only take with water
    • renal Fxn needs to be high
    • foods high in metals can slow absorption
  • Denosumab
    • reduces bioresorption
    • for pt that has osteoporosis but cannot be on bisphosphonate
  • Teriparatide (Forteo)
    • Stimulates bone formation (unique!!)

Selective estrogen receptor modulator or SERM

  • raloxifene (evista)
    • less bone loss
    • do not give if any coagulopathies are present

Pramipexol (Mirapex)

  • not miralax
  • for RLS
    • and used in parkinson’s
  • narcoleptic effects, and drowsiness

Rheumatoid arthritis   

  • autoimmune, symmetrical stiffness
  • systemic S/S: thinning and nodules under skin,
  • wake up with pain in joints, and with more movement it improves
  • DMARD – disease modifying antiRA drugs
    • stops inflammation and autoimmune function to delay function
  • treat s/s then try to get function back and treat pain.
  • Plaquenil
    • non-biologic DMARD
  • Etanercept (enbrel)
  • biologic are most expensive

gout

  • cannot process uric acid
  • chronic inflammatory disorder
    • uric acid crystals form in the night when the blood flow is low
      • this causes toe pain
  • treat with NSAID for pain and inflammation
    • watch for GI upset and do not take with ETOH
  • Uloric allopurinol
    • preventative for chronic gout

Posins

prevention is best

identify the problem

irrigate the poison on the skin

  • the solution to pollution is dilution

removal

  • lavage through large bore tube
  • activated charcoal
    • powder, mixed in water and
  • ipecac to throw up
    • mallory weiss tear from violent puking
    • vomiting like the exorcist
  • sodium bicarb to raise ph of blood
    • also increase renal excretion
  • mental health drugs do not commonly dialize

antidotes

  • metal:
    • chelation
  • anticholinergic
    • physostigmine
  • non depol NM blocker
    • neostigmine
  • ACHase inhibitors
    • atropine
  • opiates
    • narcan
  • Benzos
  • acetaminophen
    • mucomyst, protects the kidney
  • Radiation
    • iodine to protects the thyroid from problems in the future.
  • Nerve Gas
    • Atropine, and 2-PAM chloride (hold the auto injector to the leg for 5-10 seconds)
      • you can die from too much of this antidote.

herbs

  • echinacea
    • for cold, not for prevention. doesn’t work well, does not work in kids
  • zink
    • same as echinacea
  • glucosamine
    • turns into chondroitin in the body
    • shoulders are weird, some people have reduced pain in the shoulder with this
    • sulfa allergy
  • CQ10
    • when taking lipid drugs
    • to replenish the body’s own CQ10
    • might as well take it
  • omega 3
    • lowers triglycerides.
  • niacin
    • increases chances for hemorrhagic stroke.
  • vit E
    • antioxidant
    • toxic in over 1500 IU/ day
    • makes cancer grow faster
  • st.john’s wort
    • SSRI drug
    • for mild depression

Pharmacology Session 10:

Hemophilia – decreased number of RBC’s

Causes

  • blood loss
  • Iron deficiency
  • RBC lysis
  • ?
  • Most common is iron deficiency
  • microcytic, hypochromic
  • pale RBC
  • the oral iron supplement is taken through as straw
    • so it doesnt stain teeth
  • can cause chelation
  • S/E constipation, use with caution in kids (toxicity)
  • Use z-track for IM
  • antidote is deferoxamine for OD
  • B12 deficiency Anemia (pernicious anemia and people did die from it in the olden days)
    • need b12 to catalyze folic acid
      • dark red meats
    • need intrinsic factor (IF) to absorb b12
    • neurologic and GI issues:
      • hallucinations, memory issues,
    • used to be given IM only, now can be given po routes as well
    • megaloblastic – big RBC
  • Folic acid anemia (similar to b12)
    • get folic acid from dark leafy greens
  • RBC production
    • EPO – Epoetin A
      • mimics erythropoietin
    • chronic renal failure, anemia of chronic disease or from chemo.
      • these people can use EPO
    • cyclists take this (illegally) to improve performance.
  • WBC production
    • Filgrastim (neupogen)
      • very expensive
      • stim growth of WBC
  • Thrombopoietic GF (thrombocyte production)
    • Oprelvekin (interleukin) thrombopoietin

Hemostasis is important to stop the loss of blood through a cut, and allow the tissues to start the repair process.

Virchow’s triad – stasis, vessel injury, and hypercoagulability

Thrombosis (clot) – from a local tissue ingury in the artery, and in the vein it often comes from blood that is too slow so a clot can form, and eventually break of the vessel wall.

Anticoags effect Clotting cascade in these ways:

  • Platelet aggregation

do not give an anticoag in active hemorrhage, hemophilia, and pregnancy*.

  • Heparin through sq or IV
    • blocks the clotting cascade at Xa and XIa
    • used for the prevention of more clots, and post op thrombous
      • ***only giving in pregnancy (SQ) if the mom has a preexisting bleeding disorder
      • These do not dissolve the clot, but only prevent the clot
    • S/E: Hemorrhage, HIT, petechiae, BLEEDING GUMS,
    • if OD use Protamine sulfate
    • Test:
      • aPTT normal is 40 sec, Normal range on heparin or coumadin is sixty to eighty seconds
    • Lovenox is low molecular weight heparin.
    • Measured in Units/ml
      • can be as high as 10,000 units per mil
    • HIT – heparin induced thrombocytopenia
      • if this process occurs the patient can NEVER get heparin again
      • use Argatroban if HIT occurs
  • LMWH – low molecular weight heparin
    • Enoxaparin (lovenox) -heparin
      • patient can do self injections sq
      • no need for
  • Dabigatran (pradaxa)
    • Direct thrombin inhibitor
    • Very expensive
    • for reduction of stroke risk in an patient without  nonvalvular atrial fibrillation
  • Xarelto – Xa inhibitor
  • Warfarin (coumadin)
    • works in the liver to inhibit production of the clotting factors
    • Highly absorbed and bound to proteins
    • for long term prevention of thrombosis, Afib, pulmonary embolism
    • Vit K is antidote not K + not potassium.
    • TERATOGENIC
      • pregnant moms that need this drug should switch to heparin
    • lots of DD interactions
      • quinidine, antibi, NSAIDS, cimetidine, and T hormones
    • INR test on coumadin between 2-3 for heart valve 3-4.5
    • takes days for effect
      • heparin only takes about one and a half hours
  • Thrombolytics
    • bleeding is a big problem
      • so put in all of your lines first then give the drug.
    • only give in early clot development so to not create an embolis
  • antiplatelet
    • ASA – suppresses platelet aggregation by blocking the enzyme that makes the platelets “sticky”
      • prevention of MI
    • Clopidogrel (plavix)
      • can be used with ASA
      • Herbs that increase bleeding time
        • ginger, ginseng, garlic
  • peripheral neuropathy is unique to vincristine