NR z565: zAdvanced zPharmacology zmidterm zstudy
zguide
Week z1
• - zDrug zSchedules z Descriptions zof zeach zschedule
• Examples zof zdrugs zin zeach zschedule
Schedule zI zControlled zSubstances
Substances zin zthis zschedule zhave zno zcurrently zaccepted zmedical zuse zin zthe
zUnitedzStates, za zlack zof zaccepted zsafety zfor zuse zunder zmedical zsupervision,
zand za zhigh zpotential zfor zabuse.
Some zexamples zof zsubstances zlisted zin zSchedule zI zare: zheroin,
zlysergic zacid zdiethylamide z(LSD), zmarijuana z(cannabis), zpeyote,
zmethaqualone, zand z3,4-zmethylenedioxymethamphetamine z("Ecstasy").
Schedule zII/IIN zControlled zSubstances z(2/2N)
Substances zin zthis zschedule zhave za zhigh zpotential zfor zabuse zwhich zmay
zlead ztozsevere zpsychological zor zphysical zdependence.
Examples zof zSchedule zII znarcotics zinclude: zhydromorphone z(Dilaudid®),
zmethadone z(Dolophine®), zmeperidine z(Demerol®), zoxycodone z(OxyContin®,
zPercocet®), zand zfentanyl z(Sublimaze®, zDuragesic®). zOther zSchedule zII
znarcoticszinclude: zmorphine, zopium, zcodeine, zand zhydrocodone.
Examples zof zSchedule zIIN zstimulants zinclude: zamphetamine
z(Dexedrine®, zAdderall®), zmethamphetamine z(Desoxyn®), zand
zmethylphenidate z(Ritalin®).
Other zSchedule zII zsubstances zinclude: zamobarbital, zglutethimide,
zandzpentobarbital.
Schedule zIII/IIIN zControlled zSubstances z(3/3N)
Substances zin zthis zschedule zhave za zpotential zfor zabuse zless zthan zsubstances
zin zSchedules zI zor zII zand zabuse zmay zlead zto zmoderate zor zlow zphysical
zdependence zorzhigh zpsychological zdependence.
Examples zof zSchedule zIII znarcotics zinclude: zproducts zcontaining znot zmore
zthan z90zmilligrams zof zcodeine zper zdosage zunit z(Tylenol zwith zCodeine®),
zand zbuprenorphine z(Suboxone®).
Examples zof zSchedule zIIIN znon-narcotics zinclude: zbenzphetamine
z(Didrex®), zphendimetrazine, zketamine, zand zanabolic zsteroids zsuch zas
zDepo®-Testosterone.
Schedule zIV zControlled zSubstances
,Substances zin zthis zschedule zhave za zlow zpotential zfor zabuse zrelative zto
zsubstanceszin zSchedule zIII.
Examples zof zSchedule zIV zsubstances zinclude: zalprazolam z(Xanax®),
zcarisoprodolz(Soma®), zclonazepam z(Klonopin®), zclorazepate z(Tranxene®),
zdiazepam z(Valium®), zlorazepam z(Ativan®), zmidazolam z(Versed®), ztemazepam
z(Restoril®), zand ztriazolam z(Halcion®).
Schedule zV zControlled zSubstances
Substances zin zthis zschedule zhave za zlow zpotential zfor zabuse zrelative zto
zsubstanceszlisted zin zSchedule zIV zand zconsist zprimarily zof zpreparations
zcontaining zlimited zquantities zof zcertain znarcotics.
Examples zof zSchedule zV zsubstances zinclude: zcough zpreparations zcontaining
znotzmore zthan z200 zmilligrams zof zcodeine zper z100 zmilliliters zor zper z100
zgrams z(Robitussin zAC®, zPhenergan zwith zCodeine®), zand zezogabine.
• Which zones zcan zand zcan znot zbe zprescribed zby znurse zpractitioners
➢ They zcan zprescribe zall zbut zschedule z1 zbecause zthey zare znot zlegal. zVaries zby zstate
• Prescriptive zAuthority
• Understand zwhat zprescriptive zauthority zis zand zwho zmandates zit.
➢ State zmandates zit zunder zthe zjurisdiction zof zthe zhealth zprofessional zboard.
z(state zboard zof znursing, zboard zof zmedicine zor zboard zof zpharmacy). zFederal
zgovernment zcontrols zdrug zregulations zbut zhas zno zcontrol zover zprescriptive
zauthority. zPrescriptive zauthority zis zthe zlegal zright zto zprescribe zdrugs. zFull
zauthority zis zbeing zable zto zprescribe zindependently zwithout zlimitations. zMDs
zand zDOs zhave zno zlimits.zLimitations zare ztied zto zoversight zof zthe zdoctor zor
zDO. zBeing zable zto zprescribe zindependently zmeans zis znot zsubject zto zrules
zrequiring zphysician zsupervision zor zcollaboration. zFlorida zIII-V zcollaborative.
• What zproblems zarise zwhen zit zis zlimited?
➢ Barriers zinclude zquality, zaffordable, zand zaccessible zpatient zcare. zCan
zincreasezpatient zwaits
• Know zthe zresponsibilities zof zprescribing
➢ Must zconsider zcost, zavailability, zinteractions zwith zeither zfood zor zother
zmedications, zside zeffects, zallergies, zhow zthe zdrug zis zmetabolized z(hepatic zor
zrenal),zneed zfor zmonitoring z(labs, zeffectiveness, zect) zspecial zpopulations
z(pregnancy, znursing zmothers, zor zolder zadults)
• Know zpatient zreasons zfor zmedication znon-adherence
➢ Missed za zdose, zforgot zto ztake za zdose, zdid znot zrefill zmedication zin ztime, ztook
zlowerzthan zprescribed zdose, zdid znot zrefill zmedication, zstopped ztaking
zmedication.
➢ Reason zwhy zincludes zforgot za zdose, zran zout, zwas zaway zfrom zhome, ztrying
zto zsavezmoney, zdid znot zlike zthe zside zeffects, zwas ztoo zbusy, zthe zmedication
zdidn’t zwork, zdidn’t zbelieve zmedication zwas znecessary, zdidn’t zlike ztaking zthe
zmedication. zFailurezto zcomprehend zinstructions zfor zreasons zsuch zas zvisual,
zintellectual zor zauditory zimpairment, zuse zof zcomplex zregimens z(taking zseveral
zdrugs zmultiple ztimes za zday)
, Most zcommon zis zforgetfulness. zUse zmedication zorganizers zand zincorporate
zmedsiinto za zdaily zroutine zlike zbrushing zteeth zor zeating zbreakfast.
• Know ihow iwhat itype iof ievidence iprescribers ishould iuse ito imake itreatment
irecommendations
➢ ?
• Be zfamiliar zwith zphysiological zchanges zof zaging zthat zimpact
zpharmacologicalztreatments
➢ Drug zsensitivity zvaries zwith zage. zInfants zand zolder zadults zare zespecially
zsensitivezto zdrugs. zIn zthe zvery zyoung zpatient, zheightened zdrug zsensitivity zis
zthe zresult zof zorgan zimmaturity. zIn zolder zadults, zheightened zsensitivity
zresults zlargely zfrom zdecline zin zorgan zfunction. zOther zfactors zthat zaffect
zsensitivity zin zolder zadults zare zthe zpresence zof zmultiple zcomorbidities zand
ztreatment zwith zmultiple zdrugs. zThe zdrug-metabolizing zcapacity zof zinfants zis
zlimited. zThe zliver zdoes znot zdevelop zits zfull
capacity zto zmetabolize zdrugs zuntil zapproximately z1 zyear zafter zbirth. zDuring zthe
ztimezbefore zhepatic zmaturation, zinfants zare zespecially zsensitive zto zdrugs, zand
zcare zmust zbe ztaken zto zavoid zinjury. zSimilarly, zthe zability zof zolder zadults zto
zmetabolize zdrugs zis zcommonly zdecreased. zDrug zdosages zmay zneed zto zbe
zreduced zto zprevent zdrug
toxicity. The ikidneys iof inewborns iare inot ifully ideveloped.ziUntilzitheir kidneys
ireach zi full zicapacity zi(a zi few zimonths iafter ibirth), ziinfants capacity ito
ihave ia iz
ziexcrete limited
idrugs. zi This imust ibe iaccounted ifor i when imedicating ian ziinfant. iIn ziolder
iadults, zirenal zifunction zioften zideclines. and ifewer
i Older iadults
zinephrons. ziTheihave ismaller
iloss iresults iin idecreased iblood ifiltration. zi In ziaddition,
ikidneys
iof inephrons
ivessel ichanges isuch ias ziatherosclerosis zi reduce i renal ziblood iflow. ziAs iresult, zirenal
ia
ziexcretion ziofzidrugs iis
• Be zzifamiliar
decreased. zwith zBeer’s zCriteria
➢ List zthat zidentifies zdrugs zwith za zhigh zlikelihood zof zcausing zadverse zeffects zin
zolderzadults. zDrugs zon zthe zlist zshould zbe zavoided zin zpatients zover z65
zexcept zwhen zthe zbenefits zsignificantly zoutweigh zthe zrisks.
• Know zCYP450 zinducers zand zinhibitors
Most zdrug zmetabolism zthat ztakes zplace zin zthe zliver zis zperformed zby zthe zhepatic
zmicrosomal zenzyme z system, zalso z known z z zas z z zthe zP450 z z zsystem. zThe z z zterm
zP450 zrefers zto zcytochrome zP450, za zkey zcomponent zof zthis zenzyme zsystem.
It zis zimportant zto zappreciate zthat zcytochrome zP450 zis znot za zsingle zmolecular zentity zbut
zrather za zgroup zof z12 zclosely zrelated zenzyme zfamilies. zThree zof zthe zcytochrome zP450
z(CYP) zfamilies— zdesignated zCYP1, zCYP2, zand zCYP3—metabolize zdrugs. zThe zother znine
zfamilies zmetabolize zendogenous zcompounds z(e.g., zsteroids, zfatty zacids). zEach zof zthe zthree
zP450 zfamilies zthat zmetabolize zdrugs zis zcomposed zof zmultiple zforms, zeach zof zwhich
zmetabolizes zonly zcertain zdrugs. zTo zidentify zthe zindividual zforms zof zcytochrome zP450,
zdesignations zsuch zas z CYP1A2 z(metabolizes zAcetAminophen), zCYP2D6 z(Metabolize
zCardiovascular zdrugs z2D zecho) zand zCYP3A4 z(most zcommon) zare zused zto zindicate
zspecific zmembers zof zDrugs the zCYP1, zCYP2,
zithat ziare zand zCYP3
zimetabolized zfamilies,
ziby ziP450 zrespectively.
zihepatic zienzymes ziare zisubstrates.
iithat z iincrease z ithe z irate ziDrugs
z iof z idrug z imetabolism z iare z iinducers. z iDrugs z ithat z idecrease z ithe z irate
zmetabolism
iof z idrug ziare
Inducers act icalled iinhibitors.
zon zthe zliver zto z stimulate z enzyme z synthesis. z This z process z is z known
zas zinduction. zBy zincreasing zthe zrate zof zdrug zmetabolism, zthe zamount zof zactive zdrug zis
zdecreased zand zplasma z drug zlevels z fall. z If zdosage z adjustments z are znot z made z to
zaccommodate z for z this, z a zdrug
zguide
Week z1
• - zDrug zSchedules z Descriptions zof zeach zschedule
• Examples zof zdrugs zin zeach zschedule
Schedule zI zControlled zSubstances
Substances zin zthis zschedule zhave zno zcurrently zaccepted zmedical zuse zin zthe
zUnitedzStates, za zlack zof zaccepted zsafety zfor zuse zunder zmedical zsupervision,
zand za zhigh zpotential zfor zabuse.
Some zexamples zof zsubstances zlisted zin zSchedule zI zare: zheroin,
zlysergic zacid zdiethylamide z(LSD), zmarijuana z(cannabis), zpeyote,
zmethaqualone, zand z3,4-zmethylenedioxymethamphetamine z("Ecstasy").
Schedule zII/IIN zControlled zSubstances z(2/2N)
Substances zin zthis zschedule zhave za zhigh zpotential zfor zabuse zwhich zmay
zlead ztozsevere zpsychological zor zphysical zdependence.
Examples zof zSchedule zII znarcotics zinclude: zhydromorphone z(Dilaudid®),
zmethadone z(Dolophine®), zmeperidine z(Demerol®), zoxycodone z(OxyContin®,
zPercocet®), zand zfentanyl z(Sublimaze®, zDuragesic®). zOther zSchedule zII
znarcoticszinclude: zmorphine, zopium, zcodeine, zand zhydrocodone.
Examples zof zSchedule zIIN zstimulants zinclude: zamphetamine
z(Dexedrine®, zAdderall®), zmethamphetamine z(Desoxyn®), zand
zmethylphenidate z(Ritalin®).
Other zSchedule zII zsubstances zinclude: zamobarbital, zglutethimide,
zandzpentobarbital.
Schedule zIII/IIIN zControlled zSubstances z(3/3N)
Substances zin zthis zschedule zhave za zpotential zfor zabuse zless zthan zsubstances
zin zSchedules zI zor zII zand zabuse zmay zlead zto zmoderate zor zlow zphysical
zdependence zorzhigh zpsychological zdependence.
Examples zof zSchedule zIII znarcotics zinclude: zproducts zcontaining znot zmore
zthan z90zmilligrams zof zcodeine zper zdosage zunit z(Tylenol zwith zCodeine®),
zand zbuprenorphine z(Suboxone®).
Examples zof zSchedule zIIIN znon-narcotics zinclude: zbenzphetamine
z(Didrex®), zphendimetrazine, zketamine, zand zanabolic zsteroids zsuch zas
zDepo®-Testosterone.
Schedule zIV zControlled zSubstances
,Substances zin zthis zschedule zhave za zlow zpotential zfor zabuse zrelative zto
zsubstanceszin zSchedule zIII.
Examples zof zSchedule zIV zsubstances zinclude: zalprazolam z(Xanax®),
zcarisoprodolz(Soma®), zclonazepam z(Klonopin®), zclorazepate z(Tranxene®),
zdiazepam z(Valium®), zlorazepam z(Ativan®), zmidazolam z(Versed®), ztemazepam
z(Restoril®), zand ztriazolam z(Halcion®).
Schedule zV zControlled zSubstances
Substances zin zthis zschedule zhave za zlow zpotential zfor zabuse zrelative zto
zsubstanceszlisted zin zSchedule zIV zand zconsist zprimarily zof zpreparations
zcontaining zlimited zquantities zof zcertain znarcotics.
Examples zof zSchedule zV zsubstances zinclude: zcough zpreparations zcontaining
znotzmore zthan z200 zmilligrams zof zcodeine zper z100 zmilliliters zor zper z100
zgrams z(Robitussin zAC®, zPhenergan zwith zCodeine®), zand zezogabine.
• Which zones zcan zand zcan znot zbe zprescribed zby znurse zpractitioners
➢ They zcan zprescribe zall zbut zschedule z1 zbecause zthey zare znot zlegal. zVaries zby zstate
• Prescriptive zAuthority
• Understand zwhat zprescriptive zauthority zis zand zwho zmandates zit.
➢ State zmandates zit zunder zthe zjurisdiction zof zthe zhealth zprofessional zboard.
z(state zboard zof znursing, zboard zof zmedicine zor zboard zof zpharmacy). zFederal
zgovernment zcontrols zdrug zregulations zbut zhas zno zcontrol zover zprescriptive
zauthority. zPrescriptive zauthority zis zthe zlegal zright zto zprescribe zdrugs. zFull
zauthority zis zbeing zable zto zprescribe zindependently zwithout zlimitations. zMDs
zand zDOs zhave zno zlimits.zLimitations zare ztied zto zoversight zof zthe zdoctor zor
zDO. zBeing zable zto zprescribe zindependently zmeans zis znot zsubject zto zrules
zrequiring zphysician zsupervision zor zcollaboration. zFlorida zIII-V zcollaborative.
• What zproblems zarise zwhen zit zis zlimited?
➢ Barriers zinclude zquality, zaffordable, zand zaccessible zpatient zcare. zCan
zincreasezpatient zwaits
• Know zthe zresponsibilities zof zprescribing
➢ Must zconsider zcost, zavailability, zinteractions zwith zeither zfood zor zother
zmedications, zside zeffects, zallergies, zhow zthe zdrug zis zmetabolized z(hepatic zor
zrenal),zneed zfor zmonitoring z(labs, zeffectiveness, zect) zspecial zpopulations
z(pregnancy, znursing zmothers, zor zolder zadults)
• Know zpatient zreasons zfor zmedication znon-adherence
➢ Missed za zdose, zforgot zto ztake za zdose, zdid znot zrefill zmedication zin ztime, ztook
zlowerzthan zprescribed zdose, zdid znot zrefill zmedication, zstopped ztaking
zmedication.
➢ Reason zwhy zincludes zforgot za zdose, zran zout, zwas zaway zfrom zhome, ztrying
zto zsavezmoney, zdid znot zlike zthe zside zeffects, zwas ztoo zbusy, zthe zmedication
zdidn’t zwork, zdidn’t zbelieve zmedication zwas znecessary, zdidn’t zlike ztaking zthe
zmedication. zFailurezto zcomprehend zinstructions zfor zreasons zsuch zas zvisual,
zintellectual zor zauditory zimpairment, zuse zof zcomplex zregimens z(taking zseveral
zdrugs zmultiple ztimes za zday)
, Most zcommon zis zforgetfulness. zUse zmedication zorganizers zand zincorporate
zmedsiinto za zdaily zroutine zlike zbrushing zteeth zor zeating zbreakfast.
• Know ihow iwhat itype iof ievidence iprescribers ishould iuse ito imake itreatment
irecommendations
➢ ?
• Be zfamiliar zwith zphysiological zchanges zof zaging zthat zimpact
zpharmacologicalztreatments
➢ Drug zsensitivity zvaries zwith zage. zInfants zand zolder zadults zare zespecially
zsensitivezto zdrugs. zIn zthe zvery zyoung zpatient, zheightened zdrug zsensitivity zis
zthe zresult zof zorgan zimmaturity. zIn zolder zadults, zheightened zsensitivity
zresults zlargely zfrom zdecline zin zorgan zfunction. zOther zfactors zthat zaffect
zsensitivity zin zolder zadults zare zthe zpresence zof zmultiple zcomorbidities zand
ztreatment zwith zmultiple zdrugs. zThe zdrug-metabolizing zcapacity zof zinfants zis
zlimited. zThe zliver zdoes znot zdevelop zits zfull
capacity zto zmetabolize zdrugs zuntil zapproximately z1 zyear zafter zbirth. zDuring zthe
ztimezbefore zhepatic zmaturation, zinfants zare zespecially zsensitive zto zdrugs, zand
zcare zmust zbe ztaken zto zavoid zinjury. zSimilarly, zthe zability zof zolder zadults zto
zmetabolize zdrugs zis zcommonly zdecreased. zDrug zdosages zmay zneed zto zbe
zreduced zto zprevent zdrug
toxicity. The ikidneys iof inewborns iare inot ifully ideveloped.ziUntilzitheir kidneys
ireach zi full zicapacity zi(a zi few zimonths iafter ibirth), ziinfants capacity ito
ihave ia iz
ziexcrete limited
idrugs. zi This imust ibe iaccounted ifor i when imedicating ian ziinfant. iIn ziolder
iadults, zirenal zifunction zioften zideclines. and ifewer
i Older iadults
zinephrons. ziTheihave ismaller
iloss iresults iin idecreased iblood ifiltration. zi In ziaddition,
ikidneys
iof inephrons
ivessel ichanges isuch ias ziatherosclerosis zi reduce i renal ziblood iflow. ziAs iresult, zirenal
ia
ziexcretion ziofzidrugs iis
• Be zzifamiliar
decreased. zwith zBeer’s zCriteria
➢ List zthat zidentifies zdrugs zwith za zhigh zlikelihood zof zcausing zadverse zeffects zin
zolderzadults. zDrugs zon zthe zlist zshould zbe zavoided zin zpatients zover z65
zexcept zwhen zthe zbenefits zsignificantly zoutweigh zthe zrisks.
• Know zCYP450 zinducers zand zinhibitors
Most zdrug zmetabolism zthat ztakes zplace zin zthe zliver zis zperformed zby zthe zhepatic
zmicrosomal zenzyme z system, zalso z known z z zas z z zthe zP450 z z zsystem. zThe z z zterm
zP450 zrefers zto zcytochrome zP450, za zkey zcomponent zof zthis zenzyme zsystem.
It zis zimportant zto zappreciate zthat zcytochrome zP450 zis znot za zsingle zmolecular zentity zbut
zrather za zgroup zof z12 zclosely zrelated zenzyme zfamilies. zThree zof zthe zcytochrome zP450
z(CYP) zfamilies— zdesignated zCYP1, zCYP2, zand zCYP3—metabolize zdrugs. zThe zother znine
zfamilies zmetabolize zendogenous zcompounds z(e.g., zsteroids, zfatty zacids). zEach zof zthe zthree
zP450 zfamilies zthat zmetabolize zdrugs zis zcomposed zof zmultiple zforms, zeach zof zwhich
zmetabolizes zonly zcertain zdrugs. zTo zidentify zthe zindividual zforms zof zcytochrome zP450,
zdesignations zsuch zas z CYP1A2 z(metabolizes zAcetAminophen), zCYP2D6 z(Metabolize
zCardiovascular zdrugs z2D zecho) zand zCYP3A4 z(most zcommon) zare zused zto zindicate
zspecific zmembers zof zDrugs the zCYP1, zCYP2,
zithat ziare zand zCYP3
zimetabolized zfamilies,
ziby ziP450 zrespectively.
zihepatic zienzymes ziare zisubstrates.
iithat z iincrease z ithe z irate ziDrugs
z iof z idrug z imetabolism z iare z iinducers. z iDrugs z ithat z idecrease z ithe z irate
zmetabolism
iof z idrug ziare
Inducers act icalled iinhibitors.
zon zthe zliver zto z stimulate z enzyme z synthesis. z This z process z is z known
zas zinduction. zBy zincreasing zthe zrate zof zdrug zmetabolism, zthe zamount zof zactive zdrug zis
zdecreased zand zplasma z drug zlevels z fall. z If zdosage z adjustments z are znot z made z to
zaccommodate z for z this, z a zdrug
