Frontier PC 707 Advanced Pharmacology Final Safety Exam Correct 100%

Understand and identify evidenced-based prescribing resources - Answer ACOG, American Ca Society, National lung and heart instituete, EEP, Dynamed, Lexicomp, Sanford guide, lactamed **NO PDR Understand PLLR: Drugs in Pregnancy and Lactation: Improved Benefit-Risk information. - Answer June 2015; 3 sections pregnancy-L&D, Lactation-nursing mothers; Fe/males of reproductive age; labeling updated as new information arrives, more current information to discuss risk vs benefit Type 1-IgE - Answer Immediate hypersensitivity ex) angioedema, anaphylaxis Type 2-antibody Dependent - Answer minutes to days ex) heparin induced thrombocytopenia Type 3- Immune Complex hypersensitivity - Answer ex) arthrus reaction to tetanus Type 4- non-IgE, Cell mediated delayed - Answer 48-72 hours (delayed) ex) drug rash, Eosinophilia, poison Ivy, What are ADRs? What is the APRNs responsibility in ADRs? - Answer Adverse drug reactions 1) pharmacological (predictable) 2) idiosyneratic (unpredicted/severe); APRN: document & record specific reaction & drug; injury involved; FDA reporting Concepts of pharmacokinetics and pharmacodynamics in safety. - Answer Pharmacokinetics- how body handles drug or how it moves through the Understand biotransformation, enzyme induction and inhibition and Grapefruit and CYP 450. - Answer enzyme Inhibitors: decrease CYP450 enzymes, increasing pharmacological action of the drug (more drug, more action); basically inhibit the metabolizing system. Enzyme Induction: induces the CYP450 causing increased amount of CYP450 which results in the increased metabolism, which decreases pharmacologic action of the drug. Grapefruit juice - Answer prevents certain drugs in GI system from breaking down or metabolizing, therefore when combined with certain drugs it equals increased action. Common side effects - Answer skin reactions-happen commonly; also nausea, headache, dizziness Serious side effects - Answer those that result in death; life threatening, hospitalization, dehibilitating, prolonged QT prolongation Absolute contraindication - Answer DO NOT prescribe Relative contraindication - Answer risk of not using the med may outweigh risk of using Precautions - Answer consider risk, benefits & alternatives (pregnancy/lactation, pediatric, elderly) Understand medication reconciliation and safety. - Answer Always ask about Allergies. Detail review of pt medication hx including herbals, OTCs or PRN meds DO THIS AT EVERY VISIT. A-allergies V-vitamins O-old drugs/OTC I-Interactions D-dependence M-mendel-family hx-benefits or reactions; goal of therapy -related drug class -MOA -features of specific drugs -how do they get into body (PO, inject)-metabolized and excretion Know The World Health Organization (WHO) Six Step Model of Rational Prescribing - Answer 1-define pt problem 2-specify therapeutic objective 3-choose tx 4-start tx 5-educate pt 6- monitor effectiveness Review physiologic changes in the elderly. - Answer Increased gastric PH; decreased peristalisis (increased length of time for absorption to occur); decreased muscle mass; decreased total body water (decreased distribution); decreased liver mass (effects metabolism); Also polypharmacy >5 drugs Review physiologic changes in pregnancy. - Answer Numerous changes-most drugs don't need dosage change Increased volume= decreased albumin=increased unbound drug=increased clearance Increased blood flow to organs, increased GFR Increased renal excretion Decreased gastric motility=longer transport times, increased bioavailability Ex) SSRI-3rd trimester increased metabolism & increased excretion = increased amounts, more frequent dosing because of increased excretion, and longer transport/distribution Review physiologic changes in peds. - Answer Higher rate of metabolism; drugs are less protein bound, higher water concentration= increased distribution. Dosing based on kg; Infants= organ immaturity which can increase toxicity (decreased metabolism & excretion); underdeveloped blood brain barriar=drugs readily to CNS; PO drugs not absorbed well due to variable peristalsis What is Beers list and STOPP Tools and use implications? - Answer BEERS-1991 used to identify harmful drugs for elderly; >65 START-screening tool STOPP-screening tool >65 Tools-benefit outweighs risk, use drug; Guidelines not protocols Understand the impact of genomics and metabolism. - Answer Personalization of drug; each pt responds differently to drugs based on individual genetic makeup; genetic data can guide selection of drugs & avoid ADRs; cheek swab (inadequate efficacy & safety); especially important for depression meds What is a teratogen? - Answer Causing malformation of embryo-characterized by effect at gestation time Scheduled drugs and RX writing - Answer Scheduled: controlled substances (I-V); high potential for abuse (some narcotic, some not) Prescription drugs: not all are scheduled, need a script; cannot buy over the counter ex) PCN Safety of off label prescribing - Answer Use of drugs for other conditions or in a population not studied; off label used to benefit pt-NOT illegal; *many peds meds * inform & rationale to pt and family; * document decision making process in medical record Safety of Vitamins, Minerals and Nutraceuticals - Answer *no more than 150% of RDA *A D E K-stored in liver and fat tissue (fat soluable) * B C- water soluable (excreted in fat) * 1 multivitamin is safe * metals Ca, Mg, K+-wait 2 hours before other meds esp) synthroid & tetracycline Factors that increase risk/prevent of antibiotic resistance - Answer Using them to tx virus; incorrect dosage; wrong duration; using broad spectrum Penicillins - Answer increased risk of IgE reaction; careful with cephalosporins if anaphylaxis reaction to PCN; safe in pregnancy; Macrolids-good alternative if allergic to PCN-beta lactum Tetracyclines (contraindications) - Answer NO pregnancy & lactation, no < 8years (teeth yellow & premie long bones); adverse: decreases effectiveness of oral contraceptives, chelation Fluoroquinolones (BBW) - Answer Levaquin-tendon rupture Sulfonamides (lots of stuff) Pregnancy, lactation, D2D - Answer No pregnancy & lactation, no <2; Bacteriostatic; Folic acid depletion Gm +/_ MRSA; caution in elderly-hyperkalemia & with kidney disease; Adverse: Stephen Johnson syndrome, kidney stones (check kidney clearance) Cephalosporins - Answer safe during pregnancy (category B). However, urinary tract infections are the most common infection in pregnancy, and the associated pathogens are often resistant to these medications. Macrolids - Answer Safe in pregnancy; Lots of D2D- Azithromycin (mycroplamsa) Risk-ototoxic; take on an empty stomach *kidney injury (increase water intake) Antivirals - Answer consider dosing frequency for compliance and cost Influenza: Tamiflu-CDC approved for pregnancy. sulfa interacts with antivirals, important to start tx within 48 hrs of symptoms. Shortens span and decreases symptoms Antifungals (D2D) - Answer Diflucan-safe with breastfeeding Inhibits CYP450 Contraindicated with Statins except creams Long term use (monitor liver function); can cause QT prolongation Metronidazole (anti protazoal) (pt teaching) - Answer Flagyl-important to teach about Antabuse reaction; no alcohol for 72 hours after; (azole) follow statin rule with antifungals Anti TB (D2D, supplementation) - Answer INH- monitor B6 in pregnant women Rifampin - Answer Lots of Drug to drug interactions: Interferes with contraceptives, use back up (metabolizes quickly and clears causing ovulation) Understand sulfa drug allergies - Nitrofurantoins & sulfonamides - Answer Can cause birth defects; in 3rd trimester can cause hemolytic anemia in the mother & jaundice in newborn Understand sulfa drug allergies - TMP-SMX (trimethoprim-sulfamethoxazole) - Answer Hyperkalemia and sudden cardiac death avoid in elderly and kidney disease; do not give with ACE Immunizations- safety and order - Answer TDAP-between 27-36 weeks every pregnancy (passes antibodies to fetus) Flu-approved for pregnancy 2 live vaccinations at same time otherwise must wait 4 weeks for another live vaccine 2 or more killed at same time or any other time Antacids - Answer OTC, quick acting 1st line in step tx Aluminum: aluminum hydroxide, salts=constipation; decrease absorption of warfarin, no to renal insufficiency Calcium: tums, rolaids=constipation; chelation with iron, PNV & thyroid meds Magnesium: MOM= diarrhea; do not give to pt with renal insufficiency Sodium bicarb: no pregnancy, children or GI distress, HTN=fluid overload H2RAs (review side effects) - Answer 2nd line, take longer to work, some OTC Zantac-1st line in pregnancy, few 2TD Tagament-NO pregnancy, NO warfarin, many D2D Pepcid few D2D PPIs 3rd line-tx for 8 weeks, consider deprescribing Risk-long term bone fx, gastric malignancy Prilosec-NO pregnancy Prevacid-safe in pregnancy Tagamet (cimetidine) D2D - Answer Inhibits CYP450 pathway drugs many D2D interactions Pepcid (famotidine) D2D - Answer Fewest D2D interactions Prilosec (omeprazole) - Answer Teratogenic Zantac (ranitidine) Pregnancy - Answer 1st line Prostaglandin analogs (pregnancy) - Answer Contraindicated in pregnancy Cytotec: may induce labor (PEARL: Use with chronic NSAID use; stimulates mucous secretion) Dopamine antagonist (Reglan) - Answer BBW-tardive dyskensia Laxatives - Answer 1st line Osmotic: lactulose (2-3 days), PEG (miralax)safe in pregnancy, increases fluid, MOM-sodium salts (too much=cardiac) Stimulant: use in opioid-induced and paraplegic (dependency) Surfactant: mineral oils-vit A D E K deficiency (Colace) 2nd line-Bulk: Metamucil and citricel: increase fluids, increase fiber activity Safe Antidiarrheal - Answer 1st line in pregnancy Class B: Imodium-thickens stool, use with acute diarrhea Caution: if toxin, gut needs to rid toxin; these will slow the process May also use bulk laxatives-Metamucil and Citracel or Bismuth, caution contains ASA Antiemetics - Antihistamines-H1-Ras - Diphenhydramin - Answer Caution: glaucoma, cardio, seizure, elderly Contraindicated: severe liver disease Antiemetics - Phenothiazines - Reglan - Answer tardive dyskensia Antiemetics - Phenothiazines - Phenergan - Answer black box resp depression in children DO NOT give to parkinsons, also silent pneumonia Antiemetics - Anticholenergics (scopolamine) - Answer cautiously in patients with glaucoma, seizure disorder and cardiovascular disease