NRNP 6566 Mid-term Study Guide Week 1 to 5

NRNP 6566 Mid-term Study Guide Week 1 to 5 Week 1 1. Describe the cytochrome P450 system. Describe how inducers and inhibitors affect the cytochrome system and how that affects the half-life of medications. Cytochromes P450 (CYPs) are a superfamily of enzymes containing heme as a cofactor that function as monooxygenases. In mammals, these proteins oxidize steroids, fatty acids, and xenobiotics, and are important for the clearance of various compounds, as well as for hormone synthesis and breakdown. Cytochrome P450 enzymes can be inhibited or induced by drugs, resulting in clinically significant drug-drug interactions that can cause unanticipated adverse reactions or therapeutic failures. Fluoxetine, sertraline, and fluvoxamine are believed to inhibit cytochrome P450 2C because of observed interactions with phenytoin, diazepam, and other drugs metabolized by these enzymes. Rifampicin and isoniazid are key drugs used in the treatment of tuberculosis, while rifampicin is highly effective in inducing hepatic, drug metabolic P450 enzyme. The mnemonic SICKFACES.COM can be used to easily remember common cytochrome P450 inhibitors. 1. Sodium valproate. 2. Isoniazid. 3. Cimetidine. 4. Ketoconazole. 5. Fluconazole. 6. Alcohol & Grapefruit juice. 7. Chloramphenicol. 8. Erythromycin. 2. Describe the affect on low and high albumin levels on active drug levels especially for drugs that are highly protein bound. Albumin is the plasma protein with the greatest capacity for binding drugs. Binding to plasma proteins affects drug distribution into tissues, because only drug that is not bound is available to penetrate tissues, bind to receptors, and exert activity. As free drug leaves the bloodstream, more bound drug is released from binding sites. Some drugs have a high affinity for binding to serum proteins and may be 95% to 98% protein bound. With highly protein bound drugs, low albumin levels (as in protein-calorie malnutrition, or chronic illness) may lead to toxicity because there are fewer than the normal sites for the drug to bind. The amount of free drug is significantly increased in that case. Competition for binding sites is one important way that drugs might interact. If a patient is using two highly protein bound drugs at the same time, there will be competition for binding sites on the albumin. The drug with the greatest affinity for the albumin will bind, and is thought to disrupt the normal ratio of free to bound drug for the second medication. As a result, the second medication will be more available to distribute to the site of action and potentially cause side effects. 3. Describe ways to lessen the hepatic first pass effect Some drugs, such as propranolol or enalapril, undergo significant metabolism during a single passage through the liver. This is called the first-pass effect. When drugs are highly susceptible to the first-pass effect, the oral dose needed to cause a response will be significantly higher than the intravenous dose used to cause the same response. Alternative routes of administration, such as suppository, intravenous, intramuscular, inhalational aerosol, transdermal, or sublingual, avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation. 4. Be able to calculate creatinine clearance using the Cockgraft Gault equation The Cockcroft-Gault formula for estimating creatinine clearance (CrCl) should be used routinely as a simple means to provide a reliable approximation of residual renal function in all patients with CKD. The formulas are as follows: - CrCl (male) = ([140-age] × weight in kg)/(serum creatinine × 72) - CrCl (female) = CrCl (male) × 0.85 5. Describe what determines the frequency of drug administration Plasma concentration data collected from this type of study is plotted against time and analyzed in order to understand the behavior of a specific drug in the body. This type of pharmacokinetic data, collected from average adults, is the basis for determining dose, dosing intervals, and limitations on the safe use of a drug. Absorption, distribution, metabolism, and elimination or ADME. 6. Be familiar with the Beers criteria and how to use it The 2019 update uses the five criteria outlined in 2015; these include medications that should typically be avoided in most older patients, medications that should be avoided in older patients with certain conditions, medications that should be used with caution because of benefits that may offset risks, medication interactions, and changes in dosing based on kidney function. In addition to these criteria, decisions about medications should take into account a variety of factors, including stopping medications when they are no longer beneficial. 7. Describe factors that affect absorption, distribution, metabolism and excretion The rate and extent of absorption depends on the route of administration, the formulation and chemical properties of the drug, and physiologic factors that can impact the site of absorption. The acid environment or presence of food in the stomach, the solubility and other chemical properties of the drug, and the effect of the initial exposure to metabolic processes in the liver may all reduce the amount of drug that reaches the systemic circulation after oral administration, thereby reducing the bioavailability of the drug. Patient variables that can affect distribution include body composition, cardiac decompensation (heart failure), age of the patient, and albumin levels. Factors affecting metabolism include genetics, age, and drug/drug reactions. 8. Define narrow therapeutic index How would you monitor a patient with a narrow therapeutic index? Narrow therapeutic index (NTI) drugs are defined as those drugs where small differences in dose or blood concentration may lead to dose and blood concentration dependent, serious therapeutic failures or adverse drug reactions. We defined the following drugs to be NTI- drugs: aminoglycosides, ciclosporin, carbamazepine, digoxin, digitoxin, flecainide, lithium, phenytoin, phenobarbital, rifampicin, theophylline and warfarin. Frequent lab monitoring would be needed to maintain the narrow index. 9. Describe how aging affect absorption, distribution, metabolism, and excretion With age, body fat generally increases and total body water decreases. Increased fat increases the volume of distribution for highly lipophilic drugs and may increase their elimination half-lives. Aging results in a number of significant changes in the human liver including reductions in liver blood flow, size, drug-metabolizing enzyme content, and pseudocapillarization. Drug metabolism is also influenced by comorbid disease, frailty, concomitant medicines, and genetics. Organ function gradually declines with age and the elderly may poorly tolerate drugs that require metabolism. Usually, age does not greatly affect clearance of drugs that are metabolized by conjugation and glucuronidation (phase II reactions). First-pass metabolism (metabolism, typically hepatic, that occurs before a drug reaches systemic circulation) is also affected by aging, decreasing by about 1%/yr after age 40. Week 2 and 3 1. Identify and describe 12 lead EKGs that demonstrate: a. 1st, 2nd, and 3rd degree AV blocks b. STEMI in any lead (know what area of the heart is affected based on lead location) c. Atrial fibrillation and flutter d. Ventricular fibrillation and tachycardia e. Asystole EKG strips page 351. 2. Identify and describe the medications to treat each one of the EKGS listed in #1 1st degree – Rarely needs treatment, Pacemaker if symptomatic. 2nd degree – Rarely needs treatment, Evaluate meds, electrolytes, and thyroid function. Echo to R/O heart disease. 3rd degree – IV atropine can be given for S/S of poor perfusion, immediate EP consult for pacemaker placement STEMI – MONA Afib/flutter – AV node blockers, beta blockers, antiarrhythmics. Cardioversion. Rate vs Rhythm V-fib – D-fib first followed by 1 mg Epinephrine, Amiodarone 300 mg, Mg 2 g. V-tach – Amiodarone, Mexiletine, Sotalol 3. Distinguish between dihydropyridine and non-dihydropyridine calcium channel blocker. Know what conditions each class would be used to treat. Dihydropyridines are more selective to smooth muscle. Because they reduce systemic vascular resistance and arterial pressure, dihydropyridines are used to treat hypertension. Two examples of medications in this class are amlodipine and nifedipine. Non-dihydropyridines are more selective to the myocardium. Verapamil has a very important role in treating angina (by reducing myocardial oxygen demand and reversing coronary vasospasm) and arrhythmias.