NR567 / NR 567 Final Exam 2026 Update | Advanced Pharmacology for the AGACNP | Chamberlain University | Questions & Answers with Detailed Rationales | Grade A | Acute Care Pharmacology & AGACNP Board Prep PDF

INSTANT PDF DOWNLOAD — This is the comprehensive final exam preparation guide for NR567 / NR 567 - Advanced Pharmacology for the Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) (2026 Update) at Chamberlain University, featuring questions and answers with detailed rationales. Designed for AGACNP students, this resource consolidates the critical pharmacologic principles required to master the NR567 final exam and excel in acute care pharmacology and AGACNP board certification. The guide is meticulously aligned with Chamberlain University curriculum, ANCC and AACN AGACNP certification blueprints, and current evidence-based pharmacotherapy guidelines. This verified resource provides comprehensive coverage of key NR567 Advanced Pharmacology exam topics, including: Pharmacokinetics and Pharmacodynamics (absorption (bioavailability, first-pass effect, enteral vs parenteral routes), distribution (volume of distribution, protein binding, blood-brain barrier), metabolism (phase I (CYP450 system—oxidation, reduction, hydrolysis), phase II (conjugation—glucuronidation, acetylation, sulfation), CYP450 inducers (rifampin, carbamazepine, phenytoin, phenobarbital, St. John's wort) and inhibitors (ketoconazole, erythromycin, clarithromycin, grapefruit juice, ciprofloxacin, fluconazole, amiodarone, diltiazem, verapamil, ritonavir), CYP2D4, CYP3A4, CYP2D6 (genetic polymorphisms—poor metabolizers vs ultrarapid metabolizers)), elimination (renal excretion (glomerular filtration, tubular secretion, reabsorption), half-life, steady state, clearance); Cardiovascular Pharmacology (antihypertensives—ACE inhibitors (lisinopril, enalapril—dry cough, angioedema, hyperkalemia, renal impairment, contraindicated in pregnancy), ARBs (losartan, valsartan—similar efficacy, no cough), calcium channel blockers (dihydropyridines (amlodipine, nifedipine—peripheral edema, headache, flushing, gingival hyperplasia), non-dihydropyridines (verapamil, diltiazem—negative inotropy, chronotropy, dromotropy, constipation, AV block, heart failure exacerbation, avoid in systolic HFrEF except amlodipine, felodipine), beta-blockers (cardioselective (metoprolol, atenolol, bisoprolol—bronchospasm less, mask hypoglycemia, bradycardia, hypotension, fatigue, sexual dysfunction, avoid abrupt withdrawal), non-selective (propranolol, nadolol, carvedilol, labetalol—bronchospasm, cold extremities), alpha-beta (carvedilol, labetalol), contraindications (uncompensated heart failure (except carvedilol, metoprolol succinate, bisoprolol), severe bradycardia, heart block first degree, cardiogenic shock, severe asthma), diuretics (loop (furosemide, bumetanide, torsemide—potent, ototoxicity, hypokalemia, hypomagnesemia, hypocalcemia, metabolic alkalosis, sulfa allergy cross-reactivity (furosemide, bumetanide, torsemide—but cross-reactivity low, can use cautiously), thiazide (HCTZ, chlorthalidone, metolazone—mild, hypokalemia, hyponatremia, hypercalcemia, hyperglycemia, hyperlipidemia, hyperuricemia, sulfa allergy), potassium-sparing (spironolactone, eplerenone—hyperkalemia, gynecomastia (spironolactone), antiandrogen effects), heart failure pharmacotherapy (GDMT: beta-blockers (carvedilol, metoprolol succinate, bisoprolol), ACEi/ARB/ARNI (sacubitril/valsartan—Entresto, first-line for HFrEF, replaces ACEi/ARB, monitor for hypotension, angioedema, hyperkalemia, renal impairment), aldosterone antagonists (spironolactone, eplerenone—monitor potassium, renal function), SGLT2 inhibitors (dapagliflozin, empagliflozin—reduce HF hospitalizations, CV death, regardless of diabetes, monitor for euglycemic DKA, GU infections), ivabradine (If inhibitor, reduces HR, for HFrEF with HR ≥70 on maximally tolerated beta-blocker), digoxin (monitor levels (therapeutic 0.5-0.8 ng/mL for HF, 0.8-2.0 for arrhythmias), toxicity (nausea, vomiting, visual changes (yellow-green halos, blurry vision), bradycardia, arrhythmias (VT, V-fib, heart block), hypokalemia potentiates toxicity, digoxin immune fab (Digibind/DigiFab) antidote), antiarrhythmics (Vaughan-Williams classification: Class I (Na+ channel blockers—Ia (quinidine, procainamide—proarrhythmia, QT prolongation, lupus-like syndrome (procainamide)), Ib (lidocaine, mexiletine—ventricular arrhythmias, CNS toxicity), Ic (flecainide, propafenone—negative inotropy, contraindicated in structural heart disease, increased mortality post-MI (CAST trial)), Class II (beta-blockers), Class III (K+ channel blockers—amiodarone (QT prolongation, pulmonary toxicity (cough, dyspnea, infiltrates), thyroid dysfunction (hyper or hypo), corneal microdeposits, hepatotoxicity, photosensitivity (avoid sun), blue-gray skin discoloration, neuropathy, ataxia, drug interactions (CYP3A4, CYP2C8, CYP2D6, P-gp inhibitor), dronedarone (less toxic but contraindicated in decompensated HF, permanent AF), sotalol (beta-blocker + Class III, QT prolongation, torsades, requires inpatient initiation for dose 80 mg BID), dofetilide (requires inpatient initiation, QT prolongation), ibutilide (IV only for acute conversion of AF/AFL, QT prolongation, torsades), Class IV (non-dihydropyridine CCBs—verapamil, diltiazem), other (adenosine (AV nodal blocker, for PSVT, 6mg then 12mg IV push, side effects: flushing, chest pain, dyspnea, asystole (transient), contraindicated in atrial fibrillation/flutter with WPW), digoxin), anticoagulation (warfarin (CYP2C9, VKORC1 genetics, INR goal 2-3 (2.5-3.5 for mechanical mitral valve), vitamin K antidote, drug interactions (CYP inducers/inhibitors, antibiotics, amiodarone, statins, NSAIDs, aspirin, antiplatelets), dietary interactions (vitamin K-rich foods (green leafy vegetables)), bridging with LMWH for high-risk patients (mechanical heart valve, atrial fibrillation with CHA2DS2-VASc ≥4, recent stroke/TIA, VTE 3 months)), DOACs (direct thrombin inhibitor (dabigatran—no monitoring, less drug interactions, no dietary restrictions, reversal agent: idarucizumab (Praxbind)), factor Xa inhibitors (rivaroxaban (once daily), apixaban (twice daily, lower bleeding risk than warfarin and rivaroxaban in some trials), edoxaban (once daily, after initial parenteral anticoagulation), reversal agent: andexanet alfa (Andexxa) for life-threatening/uncontrolled bleeding, not routinely for minor bleeding), DOACs contraindicated in mechanical heart valves, pregnancy, severe renal impairment (CrCl 15-30 depending on DOAC), antithrombotic therapy post-PCI (DAPT (aspirin + P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel)), duration based on stable CAD vs ACS, bleeding risk, stent type), antiplatelet agents (aspirin (COX-1 inhibitor, irreversible), clopidogrel (prodrug, CYP2C19 activation, poor metabolizers have reduced efficacy), ticagrelor (reversible, twice daily, more bleeding, dyspnea), prasugrel (prodrug, more potent, higher bleeding risk, contraindicated in prior stroke/TIA, age ≥75, weight 60 kg), cangrelor (IV, short-acting for PCI), glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide, tirofiban—high bleeding risk, thrombocytopenia), lipid-lowering therapy (statins (HMG-CoA reductase inhibitors—atorvastatin, rosuvastatin (high intensity), simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin), side effects (myalgia, myopathy, rhabdomyroidism (risk with high intensity, drug interactions (CYP3A4 inhibitors increase simvastatin, atorvastatin levels), hepatotoxicity (monitor LFTs before and after initiation, no need for routine monitoring unless symptoms), increased risk new-onset diabetes (dose-dependent), contraindicated in pregnancy), ezetimibe (cholesterol absorption inhibitor, add-on to statin or monotherapy if statin intolerant), PCSK9 inhibitors (alirocumab, evolocumab—monoclonal antibodies, for FH or ASCVD with LDL 70 on maximally tolerated statin + ezetimibe, expensive, injectable), bempedoic acid (ATP-citrate lyase inhibitor, for statin-intolerant patients), icosapent ethyl (purified EPA, for triglycerides 150 with ASCVD or diabetes + ≥2 risk factors, reduces cardiovascular events), fibrates (fenofibrate, gemfibrozil (inhibits CYP2C8, CYP2C9, CYP2C19, CYP1A2, OATP1B1—interacts with statins, increase myopathy risk), for hypertriglyceridemia, not first-line for ASCVD prevention), niacin (not recommended due to no CV benefit, increased side effects (flushing, hyperglycemia, hepatotoxicity, gout)), bile acid sequestrants (cholestyramine, colesevelam—drug interactions (bind other meds), GI side effects); Respiratory Pharmacology (asthma/COPD—SABA (albuterol, levalbuterol), LABA (salmeterol, formoterol—never monotherapy in asthma, always with ICS, formoterol has rapid onset can be used as rescue with budesonide (Symbicort SMART therapy)), SAMA (ipratropium bromide), LAMA (tiotropium, umeclidinium, glycopyrrolate, aclidinium), ICS (budesonide, fluticasone, beclomethasone, ciclesonide, mometasone—thrush, dysphonia, osteoporosis, adrenal suppression, growth suppression in children, rinse mouth after use), ICS/LABA combinations (budesonide/formoterol (Symbicort), fluticasone/salmeterol (Advair), fluticasone/vilanterol (Breo), mometasone/formoterol (Dulera)), triple therapy (ICS/LABA/LAMA—fluticasone/umeclidinium/vilanterol (Trelegy), budesonide/glycopyrrolate/formoterol (Breztri)), roflumilast (PDE4 inhibitor, for severe COPD with chronic bronchitis and frequent exacerbations, GI side effects), theophylline (narrow therapeutic index, drug interactions, toxicity (nausea, vomiting, seizures, arrhythmias)), alpha-1 antitrypsin augmentation therapy (Prolastin-C, Zemaira) for AAT deficiency with emphysema); Infectious Disease Pharmacology (antibiotic classes—penicillins (amoxicillin, ampicillin, piperacillin/tazobactam—beta-lactamase inhibitor combination), side effects (diarrhea, rash, hypersensitivity (including anaphylaxis, cross-reactivity with cephalosporins ~1-2%, carbapenems, aztreonam (low cross-reactivity)), PCN allergy (use alternative classes (macrolides, fluoroquinolones, TMP-SMX, tetracyclines, vancomycin, linezolid, daptomycin) or perform graded challenge/desensitization), cephalosporins (generations: 1st (cephalexin, cefazolin—skin/soft tissue, surgical prophylaxis), 2nd (cefuroxime, cefoxitin—CAP, intra-abdominal, pelvic), 3rd (ceftriaxone (IM/IV, once daily, biliary sludging), cefdinir, cefixime, ceftazidime (Pseudomonas coverage), cefotaxime), 4th (cefepime—Pseudomonas, broad spectrum, neurotoxicity (seizures, encephalopathy) in renal impairment), 5th (ceftaroline—MRSA, ceftobiprole, ceftolozane/tazobactam—Pseudomonas, ESBL), carbapenems (imipenem/cilastatin (seizure risk), meropenem (lower seizure risk), ertapenem (once daily, no Pseudomonas), doripenem), monobactams (aztreonam—safe in PCN allergy (no cross-reactivity), Gram-negative only, no MRSA/anaerobes), macrolides (azithromycin (long half-life, once daily, 3-5 day course, QT prolongation, GI side effects), clarithromycin (CYP3A4 inhibitor, drug interactions), erythromycin (GI intolerance, QT prolongation, motilin agonist (prokinetic)), fluoroquinolones (levofloxacin (once daily, respiratory, UTI, prostatitis), ciprofloxacin (twice daily, UTI, intra-abdominal, bone/joint, anthrax, not for respiratory (poor S. pneumo), moxifloxacin (once daily, respiratory, intra-abdominal, no UTI (renal excretion low), Black Box Warnings (tendonitis/tendon rupture (risk increased with age 60, corticosteroids, kidney/heart/lung transplant), peripheral neuropathy (irreversible), CNS effects (seizures, confusion, insomnia, dizziness, psychosis), QT prolongation, exacerbation of myasthenia gravis, aortic dissection (risk increased), phototoxicity (especially ciprofloxacin, lomefloxacin), dysglycemia (hypoglycemia and hyperglycemia, especially in elderly, diabetics, corticosteroids), hepatotoxicity, avoid in pregnancy, children (cartilage damage in animal studies), tetracyclines (doxycycline (once or twice daily, acne, rosacea, CAP, Lyme, RMSF, anthrax, malaria prophylaxis, photosensitivity, esophagitis (take with full glass water, remain upright 30 minutes), avoid in pregnancy (category D—teeth discoloration, bone inhibition), children 8 years (teeth staining, bone growth suppression), minocycline (vestibular toxicity (dizziness, vertigo, ataxia), autoimmune reactions (lupus, hepatitis, serum sickness), hyperpigmentation), tigecycline (IV only, broad spectrum including MRSA, VRE, ESBL, CRE, but increased mortality in clinical trials (reserve for limited options)), eravacycline (IV, similar to tigecycline), omadacycline (IV/PO, for CABP, ABSSSI), aminoglycosides (gentamicin, tobramycin, amikacin—Gram-negatives, synergistic with beta-lactams for enterococci, staphylococci, streptococci, nephrotoxicity (ATN, usually reversible, monitor Cr, trough levels), ototoxicity (vestibular (vertigo, ataxia, nystagmus) and cochlear (tinnitus, hearing loss, often irreversible), neuromuscular blockade (avoid with myasthenia gravis, administer slowly, calcium gluconate reversal), once-daily dosing (except pregnancy, endocarditis, burns, ascites, CrCl 30), therapeutic drug monitoring (trough 1-2 mcg/mL for gentamicin/tobramycin, peak 5-10 for synergy, 10-20 for treatment of serious infection), glycopeptides (vancomycin—MRSA, MRSE, C. diff (oral for colitis, not absorbed), Gram-positives, nephrotoxicity (especially with concomitant nephrotoxins, higher troughs (15-20), but less common with modern formulations, monitor Cr), ototoxicity (rare), red man syndrome (histamine release from rapid infusion, infusion over ≥1 hour, pretreatment with antihistamines, slow infusion rate, not an allergic reaction), thrombophlebitis (use central line or dilute, rotate sites), therapeutic drug monitoring (trough for serious MRSA infections (15-20 mcg/mL, but newer guidelines suggest 10-15 for most, 15-20 for severe/complicated), AUC-guided dosing preferred (AUC 400-600)), linezolid (oxazolidinone—MRSA, VRE, drug-resistant Streptococcus, Gram-positives, reversible myelosuppression (thrombocytopenia most common, 2 weeks, monitor CBC weekly), peripheral and optic neuropathy (irreversible, with prolonged use 28 days), serotonin syndrome (MAOI properties, avoid with SSRIs, SNRIs, TCAs, buspirone, trazodone, bupropion, meperidine, tramadol, St. John's wort, dextromethorphan, monitor for agitation, confusion, hyperreflexia, clonus, hyperthermia, discontinue linezolid and serotonergic agents, supportive care), lactic acidosis (rare, severe, with prolonged use), avoid tyramine-rich foods (hypertensive potential but less than MAOIs), tedizolid (once daily, shorter course, less myelosuppression), daptomycin (lipopeptide—MRSA, VRE, streptococci, Gram-positives, NOT for pneumonia (inactivated by surfactant), myopathy (monitor CPK weekly, muscle pain, weakness, rhabdomyolysis), peripheral neuropathy, eosinophilic pneumonia (rare, with prolonged use, fever, dyspnea, infiltrates on CXR, treat with steroids, discontinue daptomycin), dose by weight (4-6 mg/kg for skin/soft tissue, 6-8 mg/kg for bacteremia, endocarditis, osteomyelitis), polymyxins (colistin (polymyxin E), polymyxin B—last-line for MDR Gram-negatives (CRE, CRPA, CRAB), nephrotoxicity (ATN, dose-limiting, monitor Cr, urine output), neurotoxicity (paresthesias, dizziness, ataxia, confusion, seizures, respiratory failure, neuromuscular blockade (avoid with neuromuscular blockers, myasthenia gravis), dose based on renal function (colistin prodrug colistimethate, dosing complex), aerosolized for pneumonia (adjunct to IV), metronidazole (anaerobes (Bacteroides, Clostridium), C. diff, bacterial vaginosis, trichomoniasis, Giardia, amebiasis, disulfiram-like reaction with alcohol (avoid alcohol during and for 3 days after), metallic taste, dark urine (harmless), peripheral neuropathy (with prolonged use), drug interactions (warfarin (increases INR), phenytoin, phenobarbital, lithium, cyclosporine, fluorouracil, avoid with disulfiram), clindamycin (anaerobes (above diaphragm, Bacteroides fragilis resistance increasing), streptococci, staphylococci (including MRSA in some areas), C. diff infection (higher risk than other antibiotics, diarrhea, abdominal pain, fever, leukocytosis, treat with oral vancomycin or fidaxomicin), rash, hepatotoxicity (rare), neuromuscular blockade (avoid with neuromuscular blockers), TMP-SMX (UTI, PJP (treatment and prophylaxis), Nocardia, Stenotrophomonas, MRSA (some isolates), bacterial gastroenteritis (Shigella, Salmonella), travelers diarrhea, acne, toxoplasmosis (adjunct), side effects (hyperkalemia (TMP blocks renal potassium channels, especially with higher doses, monitor K+), hyponatremia, rash (including Stevens-Johnson syndrome, TEN, DRESS, photosensitivity), nephrotoxicity (crystalluria (hydrate, avoid in CrCl 15 unless PJP), thrombocytopenia (especially in elderly, with folate deficiency, monitor platelets), hyperbilirubinemia (neonates (kernicterus), avoid at term in pregnancy, in infants 2 months), megaloblastic anemia (folate antagonist, supplement folate), drug interactions (warfarin (increases INR), phenytoin (increases phenytoin levels), methotrexate (increases toxicity), digoxin (increases digoxin levels), rifampin (decreases TMP-SMX levels), cyclosporine (increases nephrotoxicity), procainamide (increases procainamide levels)), rifamycins (rifampin—TB (first-line, with INH, PZA, EMB), NTM, MRSA (adjunct, biofilm active), legionella, brucellosis, leprosy, prosthetic joint infection (biofilm), prevention of H. influenzae type b (Hib) and N. meningitidis in close contacts), potent CYP450 inducer (CYP3A4, 2C8, 2C9, 2C19, 1A2, 2B6, P-gp—major drug interactions (oral contraceptives (unintended pregnancy), warfarin, statins (simvastatin, atorvastatin), CCBs, beta-blockers, antiarrhythmics, antipsychotics, anticonvulsants, antiretrovirals, immunosuppressants (tacrolimus, cyclosporine, sirolimus), antifungals (ketoconazole, itraconazole), antivirals (protease inhibitors, NNRTIs), methadone, oral hypoglycemics, theophylline, corticosteroids, digoxin (P-gp), anticoagulants (DOACs), side effects (orange-red body fluids (urine, tears, sweat, saliva, sputum—stains contact lenses, harmless but alarming), hepatotoxicity (monitor LFTs, especially with INH, alcohol), GI intolerance, rash, thrombocytopenia, flu-like syndrome (intermittent dosing), rifabutin (less CYP induction, used with protease inhibitors, less orange discoloration, uveitis (with higher doses, clarithromycin interaction)), rifapentine (longer half-life, for LTBI (once weekly for 3 months with INH), CYP induction), antiviral agents (HIV antiretrovirals—NRTIs (tenofovir (TDF (nephrotoxicity, bone loss), TAF (less renal/bone toxicity)), emtricitabine, abacavir (hypersensitivity reaction (fever, rash, GI, respiratory, HLA-B*5701 screening required), lamivudine, zidovudine (bone marrow suppression, macrocytic anemia, myopathy)), NNRTIs (efavirenz (CNS effects (vivid dreams, dizziness, insomnia, confusion, depression, suicidal ideation), teratogenic (contraindicated in first trimester, use alternative), rash (mild to severe including SJS), CYP3A4 inducer, CYP2B6 substrate (polymorphism affects levels), drug interactions), rilpivirine (requires acidic gastric pH (avoid PPIs), QTc prolongation, CYP3A4 substrate, food requirement), doravirine (fewer drug interactions, less CNS effects), nevirapine (hepatotoxicity (including fulminant hepatitis, especially in women with CD4 250, men with CD4 400, monitor LFTs first 18 weeks, discontinue if ALT 5x ULN or clinical hepatitis), rash (including SJS/TEN, discontinue if severe, do not restart), CYP3A4 inducer), etravirine (rash (including SJS/TEN), CYP3A4 inducer, CYP2C9/2C19 inhibitor, many drug interactions), PIs (atazanavir (hyperbilirubinemia (indirect, harmless, jaundice), nephrolithiasis, PR prolongation, requires acidic gastric pH (avoid PPIs), boosted with ritonavir/cobicistat), darunavir (well tolerated, rash, hepatotoxicity, boosted), lopinavir/ritonavir (GI intolerance, QT/QTc prolongation, PR prolongation, pancreatitis, CYP3A4 inhibitor), ritonavir (pharmacokinetic booster, GI intolerance, hepatitis, CYP3A4 inhibitor, drug interactions, not active against HIV alone), boosted PIs cause metabolic complications (lipodystrophy (peripheral lipoatrophy, central adiposity, dorsocervical fat pad (buffalo hump), breast enlargement), dyslipidemia (hypertriglyceridemia, hypercholesterolemia), insulin resistance/diabetes), INSTIs (dolutegravir (first-line, high genetic barrier, twice daily for INSTI-naive, once daily, weight gain, insomnia, headache, neural tube defects (contraindicated in first trimester, per WHO? newer data suggests low risk, but CDC recommends alternative if pregnancy desired? discuss), drug interactions (CYP3A4 substrate, magnesium/aluminum antacids, calcium, iron—separate by 2-4 hours), elvitegravir (boosted with cobicistat, CYP3A4 inhibitor, drug interactions, requires booster), raltegravir (twice daily, higher risk of integrase resistance, myopathy (CPK elevation, rhabdomyolysis), drug interactions (uridine diphosphate glucuronosyltransferase (UGT)1A1 inducer/inhibitor)), bictegravir (coformulated with TAF/FTC (Biktarvy), high genetic barrier, minimal drug interactions, weight gain), entry inhibitors (maraviroc (CCR5 antagonist, requires CCR5 tropism testing (Trofile) before use, contraindicated if CXCR4-tropic or dual-mixed, hepatotoxicity, orthostatic hypotension, CYP3A4 substrate), enfuvirtide (fusion inhibitor, subcutaneous injection, injection site reactions (pain, erythema, nodules, eosinophilic cellulitis—sterile abscesses, high discontinuation rate), expensive, salvage therapy only), ibalizumab (monoclonal antibody, IV, CD4 post-attachment inhibitor, for MDR HIV, expensive, infusion reactions), fostemsavir (gp120 attachment inhibitor, for MDR HIV, oral, QTc prolongation, elevated LFTs), capsid inhibitor (lenacapavir (Sunlenca), subcutaneous injection q6 months for MDR HIV, injection site reactions, nausea), PrEP (Truvada (TDF/FTC) or Descovy (TAF/FTC) daily for HIV prevention, cabotegravir (Apretude) long-acting injectable q2 months after two monthly loading doses, superior to daily TDF/FTC), PEP (28 days of TDF/FTC + raltegravir or dolutegravir, initiate within 72 hours of exposure), HCV antivirals (direct-acting antivirals (DAAs): NS3/4A protease inhibitors (glecaprevir, voxilaprevir, grazoprevir, paritaprevir), NS5A inhibitors (ledipasvir, velpatasvir, elbasvir, ombitasvir, daclatasvir, pibrentasvir), NS5B polymerase inhibitors (sofosbuvir (nucleotide), dasabuvir (non-nucleotide)), pan-genotypic regimens (glecaprevir/pibrentasvir (Mavyret) 8 weeks for non-cirrhotic treatment-naive, epclusa (sofosbuvir/velpatasvir) 12 weeks, sofosbuvir/velpatasvir/voxilaprevir (Vosevi) for DAA failures), cure rates 95%, minimal side effects (fatigue, headache, nausea), monitoring (HCV RNA at 4 weeks (rapid virologic response), 12 weeks (SVR12—cure), LFTs), drug interactions (sofosbuvir—amiodarone (severe bradycardia, heart block, avoid or monitor inpatient), P-gp inducers (rifampin, St. John's wort decrease levels), acid-reducing agents may decrease absorption of some DAAs (separate dosing)), herpes antivirals (acyclovir, valacyclovir (prodrug, better bioavailability), famciclovir—HSV, VZV, mechanism (DNA polymerase inhibitor, requires viral thymidine kinase for activation (except acyclovir-resistant strains (TK-deficient, treat with foscarnet or cidofovir))), side effects (nephrotoxicity (crystalluria, acute interstitial nephritis, especially with rapid IV infusion, dehydration, renal impairment, hydrate, slow infusion), neurotoxicity (confusion, hallucinations, agitation, seizures, myoclonus, lethargy, especially in elderly, renal impairment, dose-adjust for CrCl 50), thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS) with high doses (rare), topical (cream, ointment—local irritation), CMV antivirals (ganciclovir (IV, myelosuppression (neutropenia, thrombocytopenia, anemia), dose-adjust for renal impairment, teratogenic, carcinogenic, gonadotoxic), valganciclovir (oral prodrug, better bioavailability, same side effects), foscarnet (CMV, acyclovir-resistant HSV/VZV, HIV, nephrotoxicity, electrolyte disturbances (hypocalcemia, hypomagnesemia, hypokalemia, hyperphosphatemia—monitor, correct before and during infusion, QTc prolongation, seizures, paresthesias, genital ulcers (painful, treat with topical anesthetics), nephrotoxicity (dose-adjust for CrCl, hydrate), cidofovir (CMV, acyclovir-resistant HSV/VZV, nephrotoxicity (dose-limiting, give with probenecid and IV hydration, monitor Cr, urine protein), neutropenia, metabolic acidosis, uveitis, iritis, carcinogenic), letermovir (CMV prophylaxis in stem cell transplant recipients, minimal myelosuppression, drug interactions (CYP3A4 substrate, cyclosporine increases letermovir levels, letermovir increases cyclosporine, tacrolimus levels—monitor)), maribavir (CMV resistant to ganciclovir, foscarnet, cidofovir, for post-transplant, side effects (dysgeusia, nausea, vomiting, diarrhea, fatigue), drug interactions (CYP3A4 substrate, increases tacrolimus, sirolimus levels, avoid strong inducers), influenza antivirals (neuraminidase inhibitors (oseltamivir (Tamiflu) PO, zanamivir (Relenza) inhaled, peramivir (Rapivab) IV), side effects (nausea, vomiting, diarrhea, headache, neuropsychiatric events (self-injury, delirium, hallucinations, especially in children, monitor), oseltamivir most common, zanamivir (bronchospasm, contraindicated in asthma, COPD), peramivir (diarrhea, neutropenia, neuropsychiatric), baloxavir marboxil (Xofluza) (cap-dependent endonuclease inhibitor, single dose, less resistance? resistance reported, diarrhea, bronchitis, nausea, avoid with dairy products (calcium reduces absorption), effective against oseltamivir-resistant strains), adamantanes (amantadine, rimantadine)—no longer recommended due to widespread resistance (99% influenza A H3N2, 100% H1N1), amantadine also for Parkinson's (dopamine agonist), side effects (CNS (insomnia, dizziness, anxiety, confusion, hallucinations, seizures), livedo reticularis, peripheral edema, anticholinergic effects), remdesivir (Veklury) (IV, for COVID-19 (FDA-approved for hospitalized patients, also for outpatients at high risk for progression (3-day course)), mechanism (RNA polymerase inhibitor, prodrug, side effects (nausea, elevated LFTs, bradycardia, hypotension, renal impairment (avoid if CrCl 30, but use possible with monitoring)), drug interactions (CYP3A4 substrate, but minimal clinical significance), nirmatrelvir/ritonavir (Paxlovid) (oral, for mild-moderate COVID-19 in high-risk outpatients, within 5 days of symptom onset, nirmatrelvir (protease inhibitor), ritonavir (booster), side effects (dysgeusia (metallic taste), diarrhea, hypertension, myalgia, drug interactions (ritonavir CYP3A4 inhibitor—many contraindications (simvastatin, lovastatin, rivaroxaban, apixaban, ergot derivatives, St. John's wort, sildenafil for pulmonary hypertension, triazolam, midazolam oral, colchicine (if renal/hepatic impairment), pimozide, lurasidone, rifampin, some antiarrhythmics, many others), dose-adjust for renal impairment (CrCl 30-59: nirmatrelvir 150 mg/ritonavir 100 mg twice daily, CrCl 30 not recommended), contraindicated in severe hepatic impairment), molnupiravir (Lagevrio) (oral, for mild-moderate COVID-19 in high-risk outpatients when Paxlovid contraindicated/unavailable, mutagenic (concern for host DNA mutation, not recommended in pregnancy, avoid in children), side effects (diarrhea, nausea, dizziness), no significant drug interactions), antifungal agents (azoles (fluconazole (CYP3A4, 2C9 inhibitor, drug interactions, hepatotoxicity, QT prolongation, alopecia (with prolonged use), congenital anomalies (contraindicated in pregnancy (high-dose first trimester associated with cleft lip/palate, heart defects), avoid except life-threatening), voriconazole (CYP3A4, 2C9, 2C19 inhibitor, visual disturbances (photopsia, altered color perception, blurred vision, reversible), hepatotoxicity, photosensitivity (risk of skin cancer, aggressive sun protection), CYP2C19 genetic polymorphisms (poor metabolizers have high levels, toxicity), intravenous formulation contains cyclodextrin (accumulates in renal impairment, use oral or monitor), drug interactions (many), posaconazole (CYP3A4 inhibitor, hepatotoxicity, QT prolongation, requires food or acidic beverage for absorption (suspension), tablet better absorption, IV for severe infection), isavuconazole (CYP3A4 inhibitor, better tolerated, less hepatotoxicity, minimal QT prolongation, shortens QTc, no photosensitivity, no visual effects, fewer drug interactions (but still CYP3A4 substrate/inhibitor), intravenous formulation contains cyclodextrin (safe in mild-moderate renal impairment, avoid in severe (CrCl 15))), echinocandins (caspofungin, micafungin, anidulafungin—candida (including azole-resistant), aspergillus (salvage, not first-line), histoplasmosis, blastomycosis, coccidioidomycosis (not first-line), side effects (hepatotoxicity (caspofungin), infusion reactions (flushing, fever, rash, bronchospasm), histamine release, thrombophlebitis, minimal drug interactions (not CYP substrate), no renal dose adjustment, safe in hepatic impairment (dose reduction for caspofungin)), amphotericin B (deoxycholate (conventional) vs lipid formulations (liposomal (AmBisome), lipid complex (ABLC), colloidal dispersion (ABCD)—lipid formulations less nephrotoxicity, but more expensive), mechanism (binds ergosterol, forms pores, fungal cell lysis, broad spectrum (candida, aspergillus, cryptococcus, histoplasma, blastomyces, coccidioides, mucor, zygomycetes, leishmania), side effects (infusion reactions (fever, chills, rigors, nausea, vomiting, headache, hypotension—pretreat with diphenhydramine, acetaminophen, hydrocortisone, meperidine for rigors, slow infusion, saline load), nephrotoxicity (dose-limiting, ATN, renal tubular acidosis, hypokalemia, hypomagnesemia, monitor Cr, K+, Mg++, hydration (1L NS before infusion), avoid other nephrotoxins, lipid formulations reduce nephrotoxicity, monitor urine output), hypokalemia (renal potassium wasting, require aggressive replacement (oral/IV), monitor for arrhythmias, digoxin toxicity), hypomagnesemia (replace, monitor), normocytic normochromic anemia (decreased erythropoietin, monitor Hgb, transfuse if symptomatic), thrombophlebitis