1. Final Exam: NR 565 / NR565(Latest 2025 Update) Advanced Pharmacology Exam Review | Weeks 5-8 Covered| Complete Guide with Questions and Verified Answers Chamberlain

Final Exam: NR 565 / NR565 (Latest 2025 Update) Advanced Pharmacology Exam Review | Weeks 5-8 Covered| Complete Guide with Questions and Verified Answers Chamberlain QUESTION A patient receives his first lab results showing an A1C of 7.2%. What is the diagnosis? Answer: -Cannot confirm because you need a second A1C after 3 months (value is borderline) QUESTION An A1C of is considered prediabetes. Answer: 5.7%- 6.4% QUESTION A random glucose of is considered diabetic. Answer: 200 with signs and symptoms QUESTION A person with diabetes has recurrent severe hypoglycemia events. What should his A1C goal be?Answer: 8% QUESTION When is it okay for a patient to have an A1C goal of 6.5%? Answer: When they can tolerate it and have no comorbidities. QUESTION How often should an A1C be monitored when stable or when unstable?- Answer: -Stable: every 6 months -Unstable: every 3 months (A1C of 7 or >) QUESTION A person comes in with an A1C of 10% and a fasting blood glucose of >300.What are the next steps for the provider? Answer: -Start insulin (when A1C is above >9% start at step 2= insulin combo therapy) QUESTION Who should not take Metformin? Answer: -Due to increased risk of Lactic acidosis: patients with CHF, older than 80 years of age, kidney disease (Renal insufficiency)QUESTION Sulfonylureas should not be used during or with or impairments. Answer: -Pregnancy -Liver -Renal QUESTION A patient who has a history of bladder cancer and HF should avoid what class of DM meds? Answer: Pioglitazones -Can cause renal fluid retention associated with HF QUESTION When is it appropriate to increase insulin needs? Answer: -Pregnancy -Infection -Stress -Growth spurts QUESTION What is the TDD of a person that weighs 70kg? Answer: TDD= (Kgx0.6) 50% will be long acting 50% Rapid actingQUESTION IF a person is eating a 50 carb meal, how much insulin will be needed based on the TDD from the above question?500 / TDD = Carb to insulin ratio 500/42 = 11.9 50/ 11 = 4.5 Units QUESTION Metformin Answer: -Best antidiabetic for patients that skip meals -Can be used to treat PCOS QUESTION A patient states that she will take her insulin lispro 30-60 minutes before a meal? Answer: Nope- must be within 15-30 mins of meal QUESTION "As long as the short-acting insulin is drawn up first I can mix my insulin glargine with it". Answer: Nope- Only NPH can be mixed with short acting -Always draw regular (Clear) before NPH (Cloudy) QUESTION A patient states, "My sugars have been around 65-68 at times but I feel like the med is working". Answer: Nope- Values are too low -Hypoglycemia unawareness, need to educateAnswer: QUESTION A woman taking Pioglitazone states, "I'm glad that this med promotes weight loss." Answer: NopePromotes an increase in LDL levels Increases cardiovascular risk -Educate about exercise and weight loss QUESTION A female patient taking Canagliflozin comes in with a UTI and 6 months ago had a fungal infection. What are your next steps? Answer: -Stop the med and start a new one QUESTION A patient taking Sitagliptin (Pioglitazone) reports abdominal pain with vomiting. What are your next steps? Answer: -Patient experiencing pancreatitis -> stop this med QUESTION Insulin onset times Answer: -Aspart= 15 - 30 mins -Regular= 30 - 60 mins -NPH= 60 - 120 mins -Glargine= 60 - 120 minsQUESTION Mechanism of Action (MOA) B2RA (Beta 2 Receptor Agonists) Promotes bronchodilation, relieving bron- chospasms, has limited role in suppressing histamine release in the lungs. QUESTION What is the first step (med) in asthma and COPD control? Answer: SABA inhaler QUESTION At what point is a patient prescribed an oral glucocorticoid? Answer: -Moderate to severe persistent asthma or for management for acute exacerbations of asthma or COPD QUESTION Roflumilast Answer: -Reduces inflammation -Not intended during pregnancy -Only used for COPD -Second line drug for COPD -Used for exacerbation prophylaxis QUESTION For Asthma, a LABA has been prescribed what other medication must a LABA be used with?Answer: Answer: -ICS QUESTION What are some benefits of using ICS? Answer: -Reduced inflammation -Safer than systemic drugs -Less side effects QUESTION What patient education can you provide for ICS use? Answer: -Rinse mouth after use to prevent candidiasis QUESTION What are some prevention strategies to prevent COPD exacerbations? Answer: - -Pulm rehab -Physical activity -Flu vaccine -Nutritional counseling QUESTION GINA Guideline steps Chart Answer:QUESTION What patient teaching can a provider give when prescribing a PPI? -S&S of hypomagnesemia (Muscle cramps, tremors, palpitations) -Supplement vitamin D and Calcium -Watch for S&S of C. Diff QUESTION What patient teaching can a provider give when prescribing a H2RA? Answer: - -Report lethargy, hallucinations, restlessness, AMS, reduced libido, impotence, and gynecomastia QUESTION Zollinger-Ellison syndrome is due to a producing tumor. Treat- ment is long-term therapy of what medication class? Answer: -Gastrin -PPI class QUESTION A patient who takes NSAIDS almost daily for arthritic pain and refuses to try another med is at risk for an NSAID-induced ulcer. The provider states... Answer: I will start a PPI to prevent an Ulcer QUESTION A pregnant patient is taking NSAIDS for pain and a Misoprostol for an ulcer. What action does the provider take?Answer: Answer: Stop the medication and switch her to a PPI Misoprostol can cause a miscarriage QUESTION A patient comes into the clinic with c/o bloating and abdominal pain for a few weeks. What are appropriate options for treatment? Answer: Lifestyle mods and H2RA QUESTION A patient has tested positive for H.Pylori. What are appropriate treatment options? Answer: Start antibiotics for 10-14 days QUESTION A pregnant woman comes in asking for GERD meds, what can you rec- ommend? Answer: Sucralafate QUESTION What is the MOA of Metaclopramide? Answer: Blocks dopamine receptors in the chemo receptor zone QUESTION Metaclopramide (Reglan) can be used for?Answer: -N/V -Diabetic Gastroparesis -Gastroesophageal refluxQUESTION What TB med is not safe for pregnancy? Answer: Ethambutol QUESTION If a mother is taking isoniazid and rifampin, can she breastfeed? Answer: -Yes QUESTION What to assess if Psyllium does not work? Answer: -Obstruction or impaction QUESTION DTaP or Tdap o Who should receive the Tdap vaccine? Answer: Teens and adults after receiving full DTaP course during childhood QUESTION Vaccine Contraindications o True contraindication for DTaP or Tdap vaccine. Answer:Moderate to severe febrile illness Hx of post-vaccination anaphylactic reaction (immediate) or encephalopathy within 7 days Caution: if prior vaccination produced a shock-like state, fever over 105 within 48 hours, persistent inconsolable crying within 48 hours lasting for 3 hours, or seizures within 3 days. QUESTION Vaccine Contraindications o Varicella Answer: Pregnancy, certain cancers, hypersensitivity to neomycin or gelatin, immunocompromised. Children should avoid salicylates for 6 weeks after QUESTION Vaccine Contraindications o Hepatitis B virus (HBV) vaccine Answer: Prior anaphylactic reaction to vaccine or baker's yeast QUESTION Examples of vaccine types o Attenuated Answer: MMR, varicella, rotavirus, influenza (intranasal) QUESTION Examples of vaccine types o Live virus Answer: MMR, varicella, rotavirus, influenzaQUESTION Examples of vaccine types o Toxoid Answer: Dtap QUESTION Examples of vaccine types o Inactive viral antigen Answer: Polio, Hep A and B, influenzas (inactivated) QUESTION Types of immunity o What are they and how is each one achieved? Answer: Herd/community - when a large group of people is immune Active - when responding to either real infection or vaccination Passive - transmitted from mother to baby or via antibodies Natural immunity - nonspecific, such as physical barriers, NK cells, etc. Acquired immunity - specific after exposure to a foreign substance, produce anti- gens Cell-mediated immunity - immune response where targets are attacked directly by cells Humoral immunity - immunity response medicated by antibodies QUESTION Definition of vaccine Answer: o a preparation containing whole or fractionated mi- croorganisms. Administration causes the recipient's immune system to manufacture antibodies directed against the microbe from which the vaccine was madeQUESTION Post exposure prophylaxis for suspected rabies bite Answer: o 4 doses of vaccine - 1ml IM on days 0,3,7,14, with RIG (rabies immune globulin) given on day 0.Those who have previously been vaccinated, 2 doses are given on days 0 and 3, no RIG QUESTION Patient teaching and assessments for post vaccine side effects Answer: o Vaccine Information Statement (VIS) on administered vaccines, Administer Tylenol to the patient before discharge, discuss reactions for administered vaccines, provide a schedule for upcoming vaccine doses, have patient wait 15 minutes before dis- charge QUESTION Who can receive attenuated influenza vaccine (FluMist)? Answer: o Healthy non-pregnant patients ages 2 49, with no hx of previous reactions to this vaccine, not immunocompromised or caring for someone who is. Contraindicated in kids with asthma or kids receiving meds with salicylates. QUESTION Pantoprazole -common doses (calculations to figure quantity) -directions for use -indication Answer: o Common Doses: 20 and 40mg delayed-release tablets and 40mg enteric-coated granules o Directions for use: Monitor for pain relief and eradication of H. pylori infection. When used long term, there is an increase for osteoporosis and fractures = maintain an adequate intake of calcium and vitamin D,and inform patients about symptoms of hypomagnesemia, including muscle cramps, palpitations, and tremors o Indication: Gastric and duodenal ulcers, as well as GERD QUESTION Metronidazole -common doses (calculations to figure quantity) -directions for use -indication Answer: o Common Doses: 500mg three times a day for 10-14 days o Directions for use: The most common side effect is nausea and headache. A disulfiram-like reaction can occur if used with alcohol and it should also not be taken during pregnancy. o Indication: H. pylori treatment (very effective against sensitive strains of H. pylori QUESTION Ondansetron -common doses (calculations to figure quantity) -directions for use -indication Answer: o Common Doses: 0.15mg/kg IV starting 30 minutes before chemo; 8mg PO TID for radiation therapy o Directions for use: Use caution with patients with electrolyte imbalances, heart failure, or brady dys- rhythmias. Can also cause prolonged QT o Indication: Chemo-induced nausea and vomiting. Is also used for the prevention of nausea and vomiting with radiation therapy and anesthesia. Can also be used for nausea and vomiting from other causes as well like gastritis and morning sickness from pregnancy. QUESTION Albuterol MDI -common doses (calculations to figure quantity) -directions for use -indicationAnswer: o Common Doses: MDI: 2 inhalations every 4-6 hours PRN o Directions for use: Used PRN for prophylaxis of exercise induced bronchospasms and are to relieve ongoing asthma attacks and COPD exacerbations. Side effects include tachycardia, angina and tremors. Use a spacer for those with hand-mouth coordination issues and if using as school (for a child), do not exceed dosage prescribed and provider should be notified if needing to use more than prescribed of SABA o Indication: SABAs are taken PRN to abort an ongoing attack. Can also be taken before exercising to prevent EIB QUESTION A patient has just been prescribed levothyroxine, the NP puts in a lab order to check TSH levels in? Answer: 6- 8 weeks QUESTION A patient comes into the clinic complaining of sore throat and fever. She has recently started Methimazole in the last 4 weeks. What does this suggest? Answer: -Agranulocytosis -Labs to check: CBC LFTs QUESTION A newly pregnant patient shows understanding of Hypothyroidism in pregnant women by stating? Answer: 2.I know that if I do not take my medicine it can cause permanent damage to my baby.3.I will need to increase my dose of medicine for a short time. (Increased by 50% from weeks 4- 8, back to normal by wk 16) QUESTION What are some food/supp interactions that can occur with levothyrox- ine? Answer: -Calcium -Iron -Magnesium -Vit C -Antacids -Take 30-60 mins before meals in the morning QUESTION What labs would you order to help diagnose thyroid conditions? Answer: -TSH -T3 -T4 -Anti TPO QUESTION What is the role of Radioactive iodine and what is a possible adverse effect? Answer: -Destruction of thyroid tissue -May need levothyroxine for life QUESTION What adjunctive med can be used for hyperthyroidism?Answer: -Beta-blockers (Mask symptoms of Hypoglycemia) -Non-radioactive iodine QUESTION Once a patient reaches a euthyroid state, how often should the be test- ed? Answer: -Once a year QUESTION A patient has a TSH of .28 (Low), a free T4 of 3 (High), and a free T3 over 650 (Very High). What med should she be started on? Answer: -Patient has Hyperthyroidism -Treatment for a thyroid storm is (to suppress hormone release): Potassium iodide Strong iodine solution Methimazole QUESTION MOA of bulk forming laxatives Answer: Absorb water into intestines, increase bulk and peristalsis -Work much like a dietary fiber-producing stool in 1-3 days QUESTION MOA of surfactants Answer: Lowers surface oil:water tension allowing more water to penetrate the stool (softens)QUESTION MOA of stimulant laxatives Answer: Increases peristalsis via intestinal nerve stimu- lation QUESTION MOA of osmotic laxatives Answer: -Causes water retention in stool (osmotic effect pulls water into gut) -Often used as bowel prep QUESTION What is the risk of laxatives in pregnancy? Answer: Can induce labor QUESTION What laxative can you give a woman who is breastfeeding? Answer: Senna QUESTION When should a person get the DTaP vaccine? Answer: -Immunocompromised (HIV, Cancer) -Pregnancy -High dose glucocorticoid useQUESTION Varicella contraindications Answer: Pregnancy and immunocompromised (HIV and cancer), hypersensitivity to neomycin or gelatin QUESTION Hep B vaccine contraindications Answer: Allergy, Baker's yeast QUESTION What is an example of a toxoid vaccine type? Answer: Tetanus DTaP QUESTION Who can receive attenuated influenza vaccines? Answer: -Anyone 2< and >50 who are not pregnant or immunocompromised QUESTION Thyroid o Diagnosis & Evaluation What labs are used to diagnose? Answer:-TSH - used primarily for screening and diag- nosing hypothyroid and for monitoring replacement therapy in hypothyroid patients -T4 - Used to monitor thyroid hormone replacement therapy and to screen for thyroid dysfunction -T3 - Useful in the diagnosis of hyperthyroidism; can also be used to monitor hormone replacement therapy -TSH low -T4 normal -T3 is high = hyperthyroidism QUESTION Thyroid o Diagnosis & Evaluation Timeframe for re-check of labs after starting levothyroxine? Answer: Recheck TSH 6-8 weeks after initiating therapy and after any dosage change; Check TSH at least once a year after serum TSH is stabilized QUESTION Thyroid o Diagnosis & Evaluation Signs and symptoms of hypothyroidism? Answer: Hypothyroidism: Depend on severity. o Mild: subtle and may go unrecognized o Moderate to severe: -Face is pale, puffy, and expressionless. -Skin cold and dry. -Hair is brittle and hair loss occurs. -Slowed Heart rate. -Patient may complain of lethargy, fatigue, and -Temperature is lowered & intolerant to cold. -Thyroid Enlargement may occur if reduced levels of T3 and T4 Mentation may be impaired.QUESTION Thyroid o Diagnosis & Evaluation Signs and symptoms of hyperthyroidism? Answer: o Elevated Heart rate and strong, and dysrhythmias and angina may develop o The CNS is stimulated, resulting is nervousness, insomnia, rapid thought flow, and rapid speech, hyperreflexia, tremors o Skeletal muscles may weaken and atrophy o Metabolic rate is raised, resulting in health and skin that is warm and moist o Feeling Hot + Heat intolerance o Appetit is increased but fails to match metabolic rate resulting in weight loss o All of these signs are referred to as thyrotoxicosis o Also usually present with exophthalmos - bulging of the eyes QUESTION Thyroid o Treatment Treatment of thyroid storm? Answer: Characterized by profound hyperthermia (105 de- grees F or higher), severe tachycardia, restlessness, agitation, and tremor. Unconsciousness, coma, hypotension, and heart failure may ensure. These symptoms are produced by excessive levels of thyroid hormone Thyroid crisis can be life threatening and requires immediate treatment. o High doses of potassium iodide or strong iodine solution are given to suppress thyroid hormone release. o Methimazole is given to suppress thyroid hormone synthesis o A beta blocker is given to reduce heart rate o Additional measures include sedation, cooling, and giving glucocorticoids and IVF QUESTION Thyroid o Treatment Result of not treating hypothyroidism during pregnancy? Answer: Can result in perma- nent neuropsychological deficits in the child - decrease child's IQ The effect of hypothyroidism is limited largely to the first trimester, a time during which the fetus is unable to produce thyroid hormone of its own Some authorities currently recommend routine screening for hypothyroidism as soon as pregnancy is confirmed Women already taking thyroid hormone replacement will need to increase dose by 50% max between weeks 4-8 of gestation and the levels will level out by week 16 QUESTION Thyroid o Treatment Medication to treat symptoms of hyperthyroidism (notice this is treating symptoms and not the hyperthyroidism itself) Answer: Methimazole - first line drug of choice (not given to women who are pregnant or breastfeeding) o Methimazole blocks synthesis of thyroid hormone. 1) Prevents the oxidation of iodine, therefore inhibiting incorporation of iodine into tyrosine. 2) prevents iodinated tyrosine from coupling Propylthiouracil - preferred treatment for thyroid storm Beta blockers - help with tachycardia experienced with hyperthyroidism QUESTION Thyroid o Treatment Drug/Food/Supplement interactions with levothyroxine Answer: Absorption of levothy- roxine is reduced by food - it should be taken on an empty stomach in the morning, at least 30-60 minutes before breakfast Drugs that reduce absorption include: H2 receptor blockers, PPIs, Carafate, Ques- tran, Colestid, Maalox/Mylanta, Tums, iron, Mag salts, XenicalDrugs that accelerate levothyroxine: Phenytoin, Carbamazepine, rifampin, Sertra- line, and phenobarbital Patients taking the following drugs may need to increase their dose of levothyroxine: Warfarin and catecholamines Levothyroxine can also increase requirements for insulin and digoxin QUESTION Diabetes o How to confirm a diagnosis prior to beginning treatment Answer: Fasting plasma glucose >/= 125mg/dl OR Random plasma glucose >/= 200mg/dl plus symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) OR Oral glucose tolerance test (OGTT): 2-hour plasma glucose >/= 200mg/dl OR HgbA1C pf 6.5% or greater - (a test that provides an estimate of glycemic control over the previous 2-3 months) is now considered a standard test as well QUESTION Diabetes o A1C General goals Answer: To keep A1C below 7% o <8% is less stringent for those with hx. Of severe hypoglycemia, limited life expectancy, pr advanced microvascular or macrovascular complications QUESTION Diabetes o A1C Older Adult goal Answer: Recommended goal for A1C in the geriatric population is 7.5-8% in older patients with moderate comorbidities and life expectancy less than 10 years o 8-8.5% for older patients with complex medical issuesQUESTION Diabetes o A1C When should insulin be considered? Answer: Recommendation: A GLP-1 should be considered before starting insulin Insulin is introduced in Step 3 which includes a 3-drug combination which includes insulin. A1C of 9% of greater would start at Step 2 with dual med therapy A1C of 10% or greater or fasting glucose of 300 or greater and is symptomatic would start on combination injectable therapy immediately (Step 4) QUESTION Diabetes o A1C At what time interval should it be re-checked? Answer: Should be monitored every 3 months until value drops to 7% and at least every 6 months thereafter QUESTION Diabetes o Action of Insulin Answer: Metabolic actions of insulin are primarily anabolic - Insulin promotes conservation of energy and buildup of energy stores, such as glycogen and the hormone also promotes cell growth and division Stimulates cellular transport (uptake) of glucose, amino acids, nucleotides, and potassium Insulin promotes synthesis of complex organic molecules In all: Under the influence of insulin - glucose is converted into glycogen, amino acids are assembled into proteins, and fatty acids are incorporated into triglycerides QUESTION Diabeteso Pioglitazone contraindications Answer: Associated with heart failure secondary to renal retention of fluid. If heart failure is diagnosed, pioglitazone should be discontinued or used in reduced dosage QUESTION Diabetes o Be familiar with abbreviations of diabetic drug classifications (GLP-1, TZD, DPP4-I, SGLT2i) Answer: .... QUESTION GLP-1: Glucagon-like Peptide-1 Receptor Agonists Answer: Dulaglutide (Trulicity) Semaglutide (Ozempic) Liraglutide (Victoza) QUESTION TZD: Thiazolidinediones Answer: Rosiglitazone (Avandia) Pioglitazone (Actos) QUESTION DPP4-I: Dipeptidylpeptidase-4 Inhibitors Answer: Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta) Alogliptin (Nesina)QUESTION SGLT2-I: Sodium-glucose co-transporter 2 Inhibitors Answer: Canagliflozin (In- vokana) Dapagliflozin (Farxiga) Empagliflozin (Jardiance) QUESTION Diabetes o Which drug class should be considered for diabetes prior to insulin? Answer: Pa- tients should always be started at step 1 with lifestyle change and metformin, unless their A1C is greater than 9%, then should be placed on 2 PO medications like in step 2 QUESTION Ratio of basal insulin to rapid-acting insulin in total daily dose (TDD) of insulin? Answer: o Total daily insulin dose (TDD) calculation includes basal insulin replace- ment and bolus insulin replacement. In all: 50% is basal dose and 50% is rapid acting Daily dose - Total weight of patient in kilograms, multiplied by 0.6. Ex: 80kg (184) x 0.6 units = 24; this means 24 units of the TDD is the basal insulin dose (long acting) (50%) and the other 24 units of rapid acting bolus/mealtime insulin (50%). QUESTION Know the carbohydrate-to insulin ratio when calculating basal insulin o Simple calculation (No calculators are allowed and will not be needed) Answer: Cal- culated using the 450 rule for regular insulin and the 500 rule for rapid acting insulin Ex for rapid acting: 500 divided by 48 = 10.4 (rounded to 10). Therefore, the carb-to-insulin ratio is 1:10 o If the meal is 60 grams of carbs, 60 divided by 10 = 6 units for carb coverageQUESTION Mechanism of Action o GLP-1 (Exenatide) (AKA mimetics) Answer: Lowers blood glucose by slowing gastric acid emptying, stimulating glucose- dependent insulin release, suppressing post- prandial glucagon release, and reducing appetite QUESTION Mechanism of Action -Biguanide (Metformin) Answer: -Decreases Glucose production by the liver QUESTION Mechanism of Action o TZD (Pioglitazone) Answer: Decrease insulin resistance and increase glucose uptake by muscle and adipose tissue -and decrease glucose production by the liver QUESTION Mechanism of Action o DPP-4i (Alogliptin) Answer: Enhance the activity of incretins (by inhibiting their break- down of DPP-4) and thereby increase insulin release, reduce glucagon release -and decrease hepatic glucose productionQUESTION Mechanism of Action o Sulfonylureas -Glipizide (Glucotrol) Answer: Promote insulin secretion by the pancreas- es; may also increase tissue response to insulin -Educate on risk of Hypoglycemia side effect QUESTION Mechanism of Action o SGLT2i (Canagliflozin) Answer: Increase glucose excretion via the urine by inhibiting SGLT-2 in the kidney tubules -decreasing glucose levels, and inducing weight loss by caloric loss through the urine QUESTION Which diabetic medication(s) come with a concern of hypoglycemia? Answer: o Sulfonylureas o Meglitinides (Glinides) o Thiazolidinediones (Glitazones) - only in the presence of excessive insulin o Glucagon-like Peptide-1 Receptor Agonists (GLP-1) (Incretin Mimetics) o Amylin Mimetics QUESTION ADA's DM Treatment Algorithm Answer: Step 1: At diagnosis, initiate lifestyle changes plus metformin. Step 2: Continue step 1 & add a 2nd drug (TZD, DPP-4, SGLT-2, or GLP-1). A sulfonylurea or basal insulin should be considered if patient doesn't achieve goal with these drugs. Step 3: 3-drug combo, including metformin.Step 4: 3 drug therapy that includes basal insulin fails to reach goals after 3-6 months, proceed to combination injectable insulin. QUESTION Methylxanthines o Who is at risk for toxicity and why? Answer: At risk: Those with liver disease, smokers, caffeine drinkers, those taking certain medications Why: Liver disease - theophylline is metabolized in the liver, and this can cause decreased metabolism which increases drug levels = toxicity Smokers - smoking can induce theophylline metabolism which increases drug clearance. Therefore, if the patient stops smoking and does not have the dose of theophylline is not decreased, the patient is at risk for developing toxicity Caffeine drinkers - Caffeine can intensify the adverse effects of theophylline on the CNS and the heart. Caffeine can also complete with theophylline for drugmetabolizing enzymes causing theophylline levels to rise. Those taking theophylline should avoid caffeine products and those containing caffeine Drugs that increase theophylline levels - cimetidine and the fluoroquinolone antibiotics (ciprofloxacin). These can elevate plasma levels of theophylline by inhibiting hepatic metabolism. The dosage of theo- phylline should be reduced when the drug is combined with these agents QUESTION Asthma & COPD o Step 1 therapy Complete this sentence: Manage with a as needed. Answer: Complete this sentence: Manage with a _SABA_ as needed. QUESTION Asthma Step 1: IntermittentAnswer: Symptoms= 2 days/week or less. Nighttime awakenings= none (2 times/month or less for 5 y.o. & up). SABA use= 2 days/week or less. Effect on activity= none. Risk for exacerbations requiring systemic glucocorticoids= 0-1 time/year. QUESTION Asthma Step 2: Mild Persistent Answer: Symptoms= more than 2 days/week but less than daily. Nighttime awakenings= 1-2 times/month (3-4 times/month for 5 y.o. & up). SABA use= more than 2 days/week but less than daily AND no more than 1 time on any day. Effect on activity= minimal activity limitation. Risk for exacerbations requiring systemic glucocorticoids= 2 or more times/6 months OR wheezing lasting more than 1 day 4 or more times/year (2 or more times/year for 5 y.o. & up). QUESTION Asthma Step 3: Moderate Persistent Answer: Symptoms= daily Nighttime awakenings= 3-4 times/month (more than once/week but less than nightly for 5 y.o. & up). SABA use= daily. Effect on activity= some activity limitation. Risk for exacerbations requiring systemic glucocorticoids= increased frequency & intensity of exacerbations or wheezing. QUESTION Asthma Step 4: Severe Persistent Answer:Symptoms= several times daily Nighttime awakenings= more than once/week (often nightly for 5 y.o. & up). SABA use= several times a day Effect on activity= severe activity limitation. Risk for exacerbations requiring systemic glucocorticoids= even greater increased frequency & intensity of exacerbations or wheezing. 0-4 y.o (STEP 3), 5-11 y.o. (STEP 3 OR 4), 12 y.o. & up (STEP 4 OR 5) QUESTION Asthma & COPD o Symptoms associated with each classification of asthma (mild-persistent, moderate-persistent, etc.). Answer: - Nighttime wakening from ages 0-4 years old is nor- mal and cannot be used in the data due to asthma nighttime wakening Steps 3-5 are more aggressive as our patients get older Pg. 575 in the book for classifications of asthma severity and recommendation for initial treatment Intermittent: symptoms 2 days a week or less No nighttime wakening SABA use is 2 days a week or less Mild-persistent: symptoms more than 2 days a week but less than daily Nighttime wakening 1-2 times a month SABA use is more than 2 days a week but less than daily Moderate-persistent: Symptoms daily Nighttime wakening 3-4 times a month SABA use is daily Severe-persistent: Symptoms several times a day Nighttime wakening more than once a week SABA use is several times a day 7 Recommended step is step 3-4 for ages 5-11 and step 4-5 for those above 12 years old (Steps on pg. 576-577 in book) QUESTION Asthma & COPD o Know examples of drug classes (SABA, LABA, ICS, etc.) Answer: SABA, LABA,Anticholinergics (ipratropium & aclindinium), inhaled corticosteroids, leukotriene receptor agonists (montelukast & zafirlukast), and oral corticosteroids (prednisone) QUESTION Asthma & COPD o SABA Know examples Answer: Examples: Albuterol, isoproterenol, levalbuterol, terbutaline sulphate QUESTION Asthma & COPD o SABA Benefits of use Patient instructions Answer: Benefits of use: Rescue inhaler, all asthma patients should have a SABA, they are for prophylaxis of exerciseinduced bronchospasms and to relieve ongoing asthma attacks and COPD exacerbations Patient instructions: How to use the inhaler (have patients demonstrate), use a spacer for those with difficulty with hand-breath coordination, patients with asthma should assess peak expiratory flow daily and compare with personal best and keep record, patients using meter dose inhalers or dry powder inhalers should have at least 1minute intervals between inhalers if using more than one, report chest pain associated with changes in HR or rhythm, do not exceed recommended dosages (Provider should be notified if symptoms require more frequent use of SABA) QUESTION Asthma & COPD o SABA Why is it important to know the frequency a patient is using their SABA?Answer: If patients are using it more frequently due to symptoms, the provider should be notified so medication changes can take place and the NP can provide adequate asthma relief QUESTION Asthma & COPD o LABA Know examples Answer: Examples: Salmeterol, formoterol, oldaterol QUESTION Asthma & COPD o LABA Benefits of use Use in COPD Answer: Benefits of use: LABAs are for patients who experience frequent attacks and dosing is done on a fixed, NOT PRN, schedule. For asthma, they must be combined with a glucocorticoid because they are not a first line therapy in asthma (FDA recommends a LABA and glucocorticoid are both contained in the same inhaler to prevent a LABA asthmaassociated death - LABA monotherapy in asthma is contraindicated) Use in COPD: LABAs are preferred over SABAs for patients with stable COPD. LABA can increase the risk for severe asthma attacks and asthma related death; however, this is not a concern for those with COPD QUESTION Asthma & COPD o Inhaled Corticosteroid (ICS) Know examples Answer:Examples: Budesonide, ciclesonide, beclomethasone QUESTION Asthma & COPD o Inhaled Corticosteroid (ICS) Benefits of use Answer: Benefits of use: Most effective drugs available for long-term control of airway inflammation. By reducing inflammation, they reduce bronchial hyper-reactivity and decrease airway mucus production in both asthma and COPD. They do not alter the course of the conditions, but they provide significant long-term control and management of symptoms QUESTION Cromolyn Answer: Used as prophylaxis for mild to moderate asthma QUESTION Monoclonal Antibodies Answer: Used for allergy-related asthma and Eosinophilic asthma QUESTION Leukotriene Receptor antagonists Answer: Second-line therapy to reduce inflamma- tion and bronchoconstrictionQUESTION B2RA (Beta 2 Receptor Agonists) Answer: Can be used PRN, for EIB, COPD exacer- bations, and maintenance therapy QUESTION Methylxanthines Answer: Maintenance therapy for chronic stable asthma QUESTION Anticholinergics Answer: Approved for bronchospasm related COPD QUESTION Asthma & COPD o At what point would an oral steroid be prescribed? Answer: May be required for patients with moderate to severe persistent asthma or for management of acute exacerbations of asthma of COPD. Because of their 8 potential for toxicity, they are prescribed only when symptoms cannot be controlled with safer medications (inhaled glucocorticoids or inhaled B2 agonists). Treatment should also be as brief as possible because of the risk for toxicity with duration of use. QUESTION Asthma & COPD o When would roflumilast be indicated for a COPD patient?Answer: For patients with severe, chronic COPD with a primary chronic bronchitis component, the risk for exacerbations may be reduced with this drug. QUESTION Smoking Cessation o Nicotine replacement How it works Answer: How it works: NRT allows smokers to substitute a pharmaceutical source of nicotine for the nicotine in cigarettes - and then gradually withdraw the replacement nicotine. This is analogous to using methadone to wean addicts of heroin. With gum, lozenges, patches, and inhaler, blood levels of nicotine rise slowly which produce less pleasure than cigarettes but do relieve symptoms of withdrawal. Long-term quit rates are greater with NRT than with placebo (although success rates still remain low). QUESTION Smoking Cessation o Nicotine replacement Patient education needed for various types Answer: Patch: Patches are applied once a day to clean, dry, nonhairy skin of the upper body or upper arm. The site should be changed daily and not reused for at least 1 week. Starting patch is determined based on the number of cigarettes smoked daily. o Adverse effects: short lived erythema, itching, and burning can occur under the patch. Discontinue patch is there is severe erythema, itching, and edema. Gum: Patients should be advised to chew the gum slowly and intermittently for approximately 30 minutes. Rapid chewing can release too much nicotine at one time which results in effects similar to those of excessive smoking (nausea, throat irritation, and hiccups). Foods and beverages can reduce nicotine absorption, so patients should not eat or drink 15 minutes before chewing the gum. Nasal spray: The nasal spray increases blood levels of nicotine rapidly like it does with smoking.Some patients are unable to give the spray up because of the similar effects to smoking that it gives. o Adverse effects my most users include rhinitis, sneezing, coughing, watering eyes, and nasal/throat irritation which usually only last a few days. Nicotine nasal spray should be avoided by patients with sinus problems, allergies, and asthma. QUESTION Smoking Cessation o Nicotine replacement Gum Answer: Gum: Patients should be advised to chew the gum slowly and intermittently for approximately 30 minutes. Rapid chewing can release too much nicotine at one time which results in effects similar to those of excessive smoking (nausea, throat irritation, and hiccups). Foods and beverages can reduce nicotine absorption, so patients should not eat or drink 15 minutes before chewing the gum. QUESTION Smoking Cessation o Nicotine replacement Patch Answer: Patch: Patches are applied once a day to clean, dry, nonhairy skin of the upper body or upper arm. The site should be changed daily and not reused for at least 1 week. Starting patch is determined based on the number of cigarettes smoked daily. o Adverse effects: short lived erythema, itching, and burning can occur under the patch. Discontinue patch is there is severe erythema, itching, and edema. QUESTION Smoking Cessation o Nicotine replacement Nasal spray Answer: Nasal spray:The nasal spray increases blood levels of nicotine rapidly like it does with smoking. Some patients are unable to give the spray up because of the similar effects to smoking that it gives. o Adverse effects my most users include rhinitis, sneezing, coughing, watering eyes, and nasal/throat irritation which usually only last a few days. Nicotine nasal spray should be avoided by patients with sinus problems, allergies, and asthma. QUESTION Wellbutrin Contraindications Answer: Seizure disorders, anorexia/bulimia, stroke, alcohol use, CNS depressants, and barbiturates. QUESTION Bupropion Recommended length of treatment Answer: 150mg PO daily for 3 days, then 150mg PO twice daily for 7-12 weeks. Treatment with Bupropion should start 1-2 weeks before smoking cessation and should decrease use after 7-12 weeks. Bupropion was the first non-nicotine drug approved as an aid to smoking cessation. It reduced the urge to smoke and reduces some symptoms of nicotine withdrawal (irritability and anxiety). QUESTION Tuberculosis (TB) o What constitutes drug-resistant TB Answer: Occurs when TB bacteria become resistant to the drugs used to treat the disease and includes multidrug-resistant (MDR TB) and extensively drug-resistant (XDR TB). MDR TB is caused by bacteria that are resistant to both isoniazid and rifampin, two potent TB drugsXDR TB infection is less common and is caused by resistance to isoniazid and rifampin as well as any fluoroquinolone and at least one of three second-line medications. These patients have a greatly decreased number of treatment options and a higher risk of death QUESTION Tuberculosis (TB) o Treatment of TB in a pregnant person, what all should be included? Answer: Rifabutin is deemed the safest during pregnancy. The CDC reports that the benefit justifies the risk for isoniazid, rifampin, and pyrazinamide. The CDC does not recommend rifapentine due to insufficient data on pregnant women. Ethambutol has caused teratogenesis in animal studies and there have been reports of eye abnormalities in children; therefore, should only be given if the benefits are deemed greater than the risks QUESTION Tuberculosis (TB) o Isoniazid (INH) is a drug that can be used to prevent TB in people that have been exposed. Answer: Primary agent for treatment and prophylaxis of TB. This drug has early bactericidal activity and is superior to alternative drugs with regard to efficacy, toxicity, ease of use, patient acceptance, and affordability. It is highly selective for M. TB. It suppressed the bacterial growth by inhibiting the synthesis of mycolic acid, a component of the mycobacterial cell wall. Because mycolic acid is not produced by other bacteria or by cells of the host, this mechanism would explain why isoniazid is so selective for tubercle bacilli. QUESTION Cold & Cough o Which drug class has no significant drug interactions Answer: Expectorants have no known significant interactions with other medicationsQUESTION Cold & Cough o Examples of decongestant Answer: Beclomethasone dipropionate, budesonide, flutica- sone, riamcinolone QUESTION H2 receptor antagonists o Examples Answer: Cimetidine (Tagamet), Famotidine, Nizatidine, and Ranitidine QUESTION H2 receptor antagonists o Which is most likely to interact due to CYP450 enzyme system? Answer: Cimetidine: it inhibits the inducers of CYP450 QUESTION Proton Pump Inhibitors o Associated vitamin and/or mineral deficiencies Answer: Can decrease absorption of calcium and can lower magnesium level QUESTION Proton Pump Inhibitors o Short-term use increases the risk of what? Symptoms this may be occurringAnswer: Risk of community-acquired pneumonia Long-term can cause C.Diff -Symptoms this may be occurring: -Pneumonia by altering the upper GI flora and impairing WBC function, this risk is only limited to the first few days of use, and then it is the same risk as nonusers QUESTION GERD o How to treat moderate to severe GERD Answer: PPIs are the best treatment for long term maintenance therapy is recommended QUESTION GERD o What medication for GERD to avoid in older adults and why? Answer: PPIs due to increased risk for fractures and dementia QUESTION GERD o Treating GERD during pregnancy Which cytoprotective agents would be used Answer: Do not use Cytotec (Misoprostol): Because prostaglandins stimulation uterine contractions and the use of this medica- tion during pregnancy has caused partial or complete expulsion of the developing fetus QUESTION GERDo When to test for h. Pylori How to treat h. Pylori Answer: Test after the failure of lifestyle modifications and OTC antacids of H2 blockers have not worked Pg. 593 table 64.2: 2 antibiotics and an antisecretory agent QUESTION PUD o Lifestyle modifications to support ulcer healing Answer: Eat 5-6 small meals per day, stop smoking, avoid NSAIDS in PUD, decrease stress and anxiety, alcohol can exacerbate PUD symptoms QUESTION Anti-diarrheal o Which one contradicted in children during or after chickenpox Answer: Bismuth (Pepto bismol): increased risk for Reye's syndrome QUESTION Anti-diarrheal o Patient teaching for ciprofloxacin for traveler's diarrhea Answer: Use drug if symptoms develop and are severe or do not improve within a few days Don't give cipro for someone who is pregnant, febrile, or has bloody diarrhea Should only be used when symptoms are severe; mild symptoms are treated with loperamide. The med can cause serious side effects, so prophylaxis is not recommendedQUESTION Anti-diarrheal o Which one is associated with gray/black stools and a black tongue Answer: Bismuth (Pepto bismol) QUESTION Constipation o Lifestyle modifications to suggest prior to treatment Answer: Increase fluids, exercise after meals, improve diet, and increase fiber QUESTION Constipation o Risks of laxatives during pregnancy Answer: GI stimulation can cause labor QUESTION Constipation o Preferred treatment during breastfeeding Answer: Senna is safe during breastfeeding. Caution with use of polyethylene glycol and bisacodyl QUESTION Constipation o Psyllium How it works and what to assess for if it doesn't produce a bowel movementAnswer: This is a bulk forming laxative. Stool swells in water to produce a viscous solution or gel which softens the fecal mass and increases its bulk. It can cause upper and lower GI obstructions QUESTION Irritable Bowel Syndrome (IBS) o A diary can be helpful to aid in diagnosis and treatment Answer: Yes, it can help manage which foods are triggers for IBS symptoms and which ones are safe to eat due to trial and error QUESTION Vomiting o How to treat gastroparesis Answer: Reglan (Metronidazole) because it increases GI motility QUESTION Vomiting Black box warning associated with treatment with Reglan (Metronidazole) Answer: - Tardive dyskinesia and parkinsonism QUESTION Metronidazole o Patient teaching needed Answer:Do not drink alcohol (can cause nausea and vomiting, dizziness, flushing, headache [hangover-like feeling]), and do not take during pregnancy