NR565 Midterm Exam | Advanced Pharmacology Study Guide
APRN prescribing role Prescriptive authority for nurse practitioners also regulates prescribing rights
beyond medications and controlled substances. These rights include therapeutic
devices and services and are outlined in state practice laws and regulations and
include Durable Medical Equipment (DME) such as wheelchairs, power scooters,
hospital beds, portable oxygen equipment, handicap placards, etc. and medical
services such as Physical Therapy (PT), Occupational Therapy (OT), home health
services, etc. Prescriptive authority encompasses more than writing a prescription
correctly. It requires adherence to ethical guidelines to ensure that patients are
safeguarded from harm. Ethical prescribing starts with being well-informed about
medications. Mechanism of action, efficacy, and safety are important
considerations, as are a patient's distinct needs and circumstances, including the
number of medications prescribed (Mitchell & Oliphant, 2016). Most patients
receiving a prescription are taking other medications, whether prescription or over-
the-counter. Appropriate selection, dosing, and duration of pharmaceutical agents
are key to maximizing outcomes and minimizing adverse effects
benefits of full practice authority Nurse practitioners have the autonomy to evaluate patients, diagnose, order and
interpret tests, initiate and manage treatments and prescribe medications, including
controlled substances without physician oversight
promoting positive outcomes through prudent prescribing Administering medications and prescribing medications are two distinct processes.
practices Prescription writing requires prudent and deliberate decision-making processes to
maintain patient safety and reduce liability, including:
*documentation of a provider-patient relationship for the recipient of the prescribed
medications
*documentation of a thorough history and physical examination for the recipient
*documentation of discussions regarding risk factors, side effects, or therapy
options
*documentation of drug monitoring or titration plan, if applicable
*documentation of consultations, if any
avoidance of prescribing medications for self, family, or friends
Rational drug selection requires a logical approach that includes the formulation of
a diagnosis based on clinical reasoning and the selection and monitoring of the
most appropriate pharmacological treatment
Considerations include: Cost, guidelines, availability, interactions, side effects,
allergies, hepatic/renal functions, need for monitoring, & special populations
Beer's Criteria identifies drugs with a high likelihood of causing adverse effects in older adults.
Accordingly, drugs on this list should generally be avoided in adults older than 65
years except when the benefits are significantly greater than the risks.
Pharmacodynamics the study of the biochemical and physiologic effects of drugs on the body and the
molecular mechanisms by which those effects are produced
Pharmacokinetics the study of drug movement throughout the body
Pharmacogenomics the study of how genes affect a person's response to drugs. The purpose of this is
to combine the sciences of genomics and pharmacology to provide individualized,
targeted, safe drug therapies to patients
Grade A+ | Updated
, NR565 Midterm Exam | Advanced Pharmacology Study Guide
CYP450 inducers Inducers are xenobiotics (medications and environmental agents) that elevate
CYP450 enzyme activity by increasing enzyme synthesis. This action leads to
additional sites available for biotransformation. The increased number of sites
enhances medication metabolism, decreasing the concentration of the "parent drug"
while increasing metabolite production.
Inducers = Increase medication metabolism
(Carbamazepine, Rifampin, Alcohol, Phenytoin, Griseofulvin, Phenobarbital,
Sulfonylureas)
CYP450 inhibitors Inhibitors are medications that inhibit the metabolic activity of one or more of the
CYP450 enzymes. Medications that inhibit an enzyme potentially slows that
enzyme's activity or blocks the activity required for the metabolism of other
medications, thereby increasing the levels of medications dependent on that
particular enzyme for biotransformation. Inhibitors = decrease medication
metabolism (Valproate, Isoniazid, Sulfonamides, Amiodarone, Chloramphenicol,
Ketoconazole, Grapefruit Juice, Quinidine)
cultural influences in prescribing The greatest concern surrounding race-based therapy has to do with genetic
variability. We know there is great diversity within and among racial groups;
therefore, a "one fits all" approach based on race is unwise. Still, we can use known
associations to guide choices. For example, differences in metabolism between
people with East Asian and European heritage are common. The provider can use
this knowledge to guide initial dosing (with adjustment, as indicated based on
response) if genetic testing is not feasible or warranted
Polypharmacy: Definition, challenges, and outcomes treatment with multiple drugs
greatly increases the risk for interactions. Some of these interactions are negligible,
but some can have life-threatening consequences. It is of crucial importance to ask
the patient about all current drugs, including over-the-counter (OTC) medications
and other herbal preparations. Many patients do not consider OTC or alternative
pharmaceuticals as "medications" and may not mention them unless you ask
specifically.
Acute Pain Management
Chronic Pain Management
Opioid Management
Regulations of Controlled Substances The U.S. Department of Justice Drug Enforcement Agency (DEA) coordinates with
local, state, and federal agents to reduce illicit drug use. The DEA enacted the
Controlled Substances Act (CSA) in 1970 to regulate drugs and other substances
based on their potential for abuse and dependency. Five schedules of controlled
substances were created that are updated annually. Classes of scheduled
substances include narcotics, depressants, stimulants, hallucinogens, and anabolic
steroids. The DEA issues eligible providers with a registration number to write
prescriptions for controlled substances. Characteristics of a valid DEA number
include:
-The first letter identifies the type of provider: A=before 1985; B=after 1985; F=after
2007; M=nurse practitioner or physician assistant
-The 2nd letter the 1st letter of the provider's last name at the time of initial
registration
Example: Tammy Greene applies for and receives a DEA number of MG2705208
M=nurse practitioner and G=Greene
Opioid Epidemic & Responsible Prescribing
Grade A+ | Updated
, NR565 Midterm Exam | Advanced Pharmacology Study Guide
Opioid Use Disorder a pattern of use that leads to significant impairment or distress. Typically, this
disorder is marked by unsuccessful efforts to reduce or control use resulting in the
inability to fulfill work, school, or home responsibilities. Opioid use disorder is
different from drug tolerance and physical dependence, which may also exist.
Opioid use creates high levels of positive reinforcement, increasing the likelihood of
continued use. It is often a chronic lifelong disorder, leading to serious
consequences such as disability and death. Although it is similar to other substance
use disorders, it has distinct features that have fueled the current opioid epidemic.
Opioids can lead to physical dependence in only 4-8 weeks. Abruptly stopping use
in chronic users leads to severe symptoms, which motivates continued use to
prevent withdrawal. The 2016 CDC guidelines for prescribing opioids recommends
calculating the total daily dose of opioids to help identify patients who might benefit
from the reduction or tapering of opioids, given the risk of overdose
State Prescription Drug Clinicians should review the patient's history of controlled substance prescriptions
using state prescription drug monitoring program (PDMP) data to determine
whether the patient is receiving opioid dosages or dangerous combinations that put
him or her at high risk for overdose. Clinicians should review PDMP data when
starting opioid therapy for chronic pain and periodically during opioid therapy for
chronic pain, ranging from every prescription to every 3 months.
Monitoring Programs safeguards to address the opioid public health crisis include prescription drug
monitoring programs (PDMPs). These electronic databases enable providers to
access information regarding a patient's prescription history of controlled
substances. Nearly all states have implemented PDMPs, and some states require
providers to check the PDMP before prescribing controlled substances. According
to the CDC (2020), PDMPs have shown promising results in changing prescribing
behaviors, decreasing the use of multiple providers by patients, and decreasing
substance abuse treatment admissions.
Drug Schedules Each drug preparation regulated under the CSA has been assigned to one of five
categories: schedule I, II, III, IV, or V. Drugs in schedule I have a high potential for
abuse and no approved medical use in the United States. In contrast, drugs in
schedules II through V all have approved applications. Assignment to schedules II
through V is based on abuse potential and potential for causing physical or
psychological dependence. Of the drugs that have medical applications, those in
schedule II have the highest potential for abuse and dependence. Drugs in the
remaining schedules have decreasing abuse and dependence liabilities.
The therapeutic window is the amount of a medication between the amount that gives an effect (effective
dose) and the amount that gives more adverse effects than desired effects. For
instance, medication with a small pharmaceutical window must be administered with
care and control, e.g. by frequently measuring blood concentration of the drug,
since it easily loses effects or gives adverse effects
Antagonist A drug that attenuates the effect of an agonist. Can be competitive or non-
competitive, each of which can be reversible or irreversible. A competitive
antagonist binds to the same site as the agonist but does not activate it, thus blocks
the agonist's action. A non-competitive antagonist binds to an allosteric (non-
agonist) site on the receptor to prevent activation of the receptor. A reversible
antagonist binds non-covalently to the receptor, therefore can be "washed out". An
irreversible antagonist binds covalently to the receptor and cannot be displaced by
either competing ligands or washing.
Agonist A drug that binds to and activates a receptor. Can be full, partial or inverse. A full
agonist has high efficacy, producing a full response while occupying a relatively low
proportion of receptors. A partial agonist has lower efficacy than a full agonist. It
produces sub-maximal activation even when occupying the total receptor
population, therefore cannot produce the maximal response, irrespective of the
concentration applied. An inverse agonist produces an effect opposite to that of an
agonist, yet it binds to the same receptor binding-site as an agonist
Silent Antagonist A drug that attenuates the effects of agonists or inverse agonists, producing a
functional reduction in signal transduction. Affects only ligand-dependent receptor
activation and displays no intrinsic activity itself. Also known as a neutral antagonist.
Grade A+ | Updated
APRN prescribing role Prescriptive authority for nurse practitioners also regulates prescribing rights
beyond medications and controlled substances. These rights include therapeutic
devices and services and are outlined in state practice laws and regulations and
include Durable Medical Equipment (DME) such as wheelchairs, power scooters,
hospital beds, portable oxygen equipment, handicap placards, etc. and medical
services such as Physical Therapy (PT), Occupational Therapy (OT), home health
services, etc. Prescriptive authority encompasses more than writing a prescription
correctly. It requires adherence to ethical guidelines to ensure that patients are
safeguarded from harm. Ethical prescribing starts with being well-informed about
medications. Mechanism of action, efficacy, and safety are important
considerations, as are a patient's distinct needs and circumstances, including the
number of medications prescribed (Mitchell & Oliphant, 2016). Most patients
receiving a prescription are taking other medications, whether prescription or over-
the-counter. Appropriate selection, dosing, and duration of pharmaceutical agents
are key to maximizing outcomes and minimizing adverse effects
benefits of full practice authority Nurse practitioners have the autonomy to evaluate patients, diagnose, order and
interpret tests, initiate and manage treatments and prescribe medications, including
controlled substances without physician oversight
promoting positive outcomes through prudent prescribing Administering medications and prescribing medications are two distinct processes.
practices Prescription writing requires prudent and deliberate decision-making processes to
maintain patient safety and reduce liability, including:
*documentation of a provider-patient relationship for the recipient of the prescribed
medications
*documentation of a thorough history and physical examination for the recipient
*documentation of discussions regarding risk factors, side effects, or therapy
options
*documentation of drug monitoring or titration plan, if applicable
*documentation of consultations, if any
avoidance of prescribing medications for self, family, or friends
Rational drug selection requires a logical approach that includes the formulation of
a diagnosis based on clinical reasoning and the selection and monitoring of the
most appropriate pharmacological treatment
Considerations include: Cost, guidelines, availability, interactions, side effects,
allergies, hepatic/renal functions, need for monitoring, & special populations
Beer's Criteria identifies drugs with a high likelihood of causing adverse effects in older adults.
Accordingly, drugs on this list should generally be avoided in adults older than 65
years except when the benefits are significantly greater than the risks.
Pharmacodynamics the study of the biochemical and physiologic effects of drugs on the body and the
molecular mechanisms by which those effects are produced
Pharmacokinetics the study of drug movement throughout the body
Pharmacogenomics the study of how genes affect a person's response to drugs. The purpose of this is
to combine the sciences of genomics and pharmacology to provide individualized,
targeted, safe drug therapies to patients
Grade A+ | Updated
, NR565 Midterm Exam | Advanced Pharmacology Study Guide
CYP450 inducers Inducers are xenobiotics (medications and environmental agents) that elevate
CYP450 enzyme activity by increasing enzyme synthesis. This action leads to
additional sites available for biotransformation. The increased number of sites
enhances medication metabolism, decreasing the concentration of the "parent drug"
while increasing metabolite production.
Inducers = Increase medication metabolism
(Carbamazepine, Rifampin, Alcohol, Phenytoin, Griseofulvin, Phenobarbital,
Sulfonylureas)
CYP450 inhibitors Inhibitors are medications that inhibit the metabolic activity of one or more of the
CYP450 enzymes. Medications that inhibit an enzyme potentially slows that
enzyme's activity or blocks the activity required for the metabolism of other
medications, thereby increasing the levels of medications dependent on that
particular enzyme for biotransformation. Inhibitors = decrease medication
metabolism (Valproate, Isoniazid, Sulfonamides, Amiodarone, Chloramphenicol,
Ketoconazole, Grapefruit Juice, Quinidine)
cultural influences in prescribing The greatest concern surrounding race-based therapy has to do with genetic
variability. We know there is great diversity within and among racial groups;
therefore, a "one fits all" approach based on race is unwise. Still, we can use known
associations to guide choices. For example, differences in metabolism between
people with East Asian and European heritage are common. The provider can use
this knowledge to guide initial dosing (with adjustment, as indicated based on
response) if genetic testing is not feasible or warranted
Polypharmacy: Definition, challenges, and outcomes treatment with multiple drugs
greatly increases the risk for interactions. Some of these interactions are negligible,
but some can have life-threatening consequences. It is of crucial importance to ask
the patient about all current drugs, including over-the-counter (OTC) medications
and other herbal preparations. Many patients do not consider OTC or alternative
pharmaceuticals as "medications" and may not mention them unless you ask
specifically.
Acute Pain Management
Chronic Pain Management
Opioid Management
Regulations of Controlled Substances The U.S. Department of Justice Drug Enforcement Agency (DEA) coordinates with
local, state, and federal agents to reduce illicit drug use. The DEA enacted the
Controlled Substances Act (CSA) in 1970 to regulate drugs and other substances
based on their potential for abuse and dependency. Five schedules of controlled
substances were created that are updated annually. Classes of scheduled
substances include narcotics, depressants, stimulants, hallucinogens, and anabolic
steroids. The DEA issues eligible providers with a registration number to write
prescriptions for controlled substances. Characteristics of a valid DEA number
include:
-The first letter identifies the type of provider: A=before 1985; B=after 1985; F=after
2007; M=nurse practitioner or physician assistant
-The 2nd letter the 1st letter of the provider's last name at the time of initial
registration
Example: Tammy Greene applies for and receives a DEA number of MG2705208
M=nurse practitioner and G=Greene
Opioid Epidemic & Responsible Prescribing
Grade A+ | Updated
, NR565 Midterm Exam | Advanced Pharmacology Study Guide
Opioid Use Disorder a pattern of use that leads to significant impairment or distress. Typically, this
disorder is marked by unsuccessful efforts to reduce or control use resulting in the
inability to fulfill work, school, or home responsibilities. Opioid use disorder is
different from drug tolerance and physical dependence, which may also exist.
Opioid use creates high levels of positive reinforcement, increasing the likelihood of
continued use. It is often a chronic lifelong disorder, leading to serious
consequences such as disability and death. Although it is similar to other substance
use disorders, it has distinct features that have fueled the current opioid epidemic.
Opioids can lead to physical dependence in only 4-8 weeks. Abruptly stopping use
in chronic users leads to severe symptoms, which motivates continued use to
prevent withdrawal. The 2016 CDC guidelines for prescribing opioids recommends
calculating the total daily dose of opioids to help identify patients who might benefit
from the reduction or tapering of opioids, given the risk of overdose
State Prescription Drug Clinicians should review the patient's history of controlled substance prescriptions
using state prescription drug monitoring program (PDMP) data to determine
whether the patient is receiving opioid dosages or dangerous combinations that put
him or her at high risk for overdose. Clinicians should review PDMP data when
starting opioid therapy for chronic pain and periodically during opioid therapy for
chronic pain, ranging from every prescription to every 3 months.
Monitoring Programs safeguards to address the opioid public health crisis include prescription drug
monitoring programs (PDMPs). These electronic databases enable providers to
access information regarding a patient's prescription history of controlled
substances. Nearly all states have implemented PDMPs, and some states require
providers to check the PDMP before prescribing controlled substances. According
to the CDC (2020), PDMPs have shown promising results in changing prescribing
behaviors, decreasing the use of multiple providers by patients, and decreasing
substance abuse treatment admissions.
Drug Schedules Each drug preparation regulated under the CSA has been assigned to one of five
categories: schedule I, II, III, IV, or V. Drugs in schedule I have a high potential for
abuse and no approved medical use in the United States. In contrast, drugs in
schedules II through V all have approved applications. Assignment to schedules II
through V is based on abuse potential and potential for causing physical or
psychological dependence. Of the drugs that have medical applications, those in
schedule II have the highest potential for abuse and dependence. Drugs in the
remaining schedules have decreasing abuse and dependence liabilities.
The therapeutic window is the amount of a medication between the amount that gives an effect (effective
dose) and the amount that gives more adverse effects than desired effects. For
instance, medication with a small pharmaceutical window must be administered with
care and control, e.g. by frequently measuring blood concentration of the drug,
since it easily loses effects or gives adverse effects
Antagonist A drug that attenuates the effect of an agonist. Can be competitive or non-
competitive, each of which can be reversible or irreversible. A competitive
antagonist binds to the same site as the agonist but does not activate it, thus blocks
the agonist's action. A non-competitive antagonist binds to an allosteric (non-
agonist) site on the receptor to prevent activation of the receptor. A reversible
antagonist binds non-covalently to the receptor, therefore can be "washed out". An
irreversible antagonist binds covalently to the receptor and cannot be displaced by
either competing ligands or washing.
Agonist A drug that binds to and activates a receptor. Can be full, partial or inverse. A full
agonist has high efficacy, producing a full response while occupying a relatively low
proportion of receptors. A partial agonist has lower efficacy than a full agonist. It
produces sub-maximal activation even when occupying the total receptor
population, therefore cannot produce the maximal response, irrespective of the
concentration applied. An inverse agonist produces an effect opposite to that of an
agonist, yet it binds to the same receptor binding-site as an agonist
Silent Antagonist A drug that attenuates the effects of agonists or inverse agonists, producing a
functional reduction in signal transduction. Affects only ligand-dependent receptor
activation and displays no intrinsic activity itself. Also known as a neutral antagonist.
Grade A+ | Updated
