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MU Pharmacology

Exam 2 Flashcards

Caffeine: Vivarin, NoDoz, caffeine citrate (Cafcit) class/indications CNS stimulant that decreases drowsiness, fatigue (drug names)
dextroamphetamine (Adderall) and methylpenidate (Ritalin)- class, action CNS stimulants that increase catecholamine activity in frontal cortex and RAS. Treatment of ADHD and narcolepsy
SE of amphetamines Increased metabolism, weight loss, BP increases (HTN)
modafinal (Provigil) indications/action Narcolepsy, sleep apnea, and shift-work sleep disorder drug. Maintains wakefulness
General action of antidepressants Increase/potentiate concentrations of norepinephrine, serotonin, dopamine in CNS
Types of antidepressants Tricyclics, MAOIs, SSRIs, Heterocyclics
SNRI Indications ADHD; adjuvant for opiods
SNRI drug name/action atomoxetine (Strattera): 1st nonstimulant, blocks reuptake of NE. Better alternative bc no abuse potential, doesn't affect growth or cause insomnia. Watch suicide ideation in teens
MAOI drug name/action/considerations phenelzine (Nardil): blocks MAO enzyme from degrading serotonin, NE, and dopamine in synapse; cannot combine with tyramine (in either foods or drugs) --> hypertensive crisis. Last resort drug.
Tricyclic Antidepressants drug/action/considerations amitriptyline (Elavil) and imipramine (Tofranil): block reuptake of NE and serotonin. Anticholinergic side effects -> watch cardiac pts. Takes 4-8 wks to work
SSRIs drug/action/considerations fluoxetine (Prozac): 1st choice, d/t no heart effects. Blocks reuptake of serotonin. Decreases libido, weight gain (as with all antidepressants), takes 4 wks.
Heterocyclic drug/action/considerations mirtazapine (Remeron), buproprion (Wellbutrin): often used if others don't work. Has varying effects on NE, serotonin, dopamine. May potentiate seizures in pt with hx. Wellbutrin also used to help quit smoking
Antimanic drug/action/considerations Lithium salts (Lithane, Eskalith): inhibits NE and serotonin (in excess during manic episodes). Watch for hyponatremia-- low Na leads to lithium toxicity- eat salty foods. Safe therapeutic range = .5-1.2 mEq. Is a Class X, contraindicated for pregnancy
Psychotropics include: (name classes) Antidepressants, SSRIs/SNRIs, CNS stimulants, antimanics, anxiolytics, antipsychotics. Any drug that acts on mental processes
General anesthetics action Blocks autonomic and muscle reflexes. Produces amnesia and analgesia (although not all); Produces unconsciousness- given in 3 steps
3 steps of general anesthesia Induction, Maintenance (when surgery occurs), Recovery
Inhalation anesthetics: drug, action, cautions isoflurane (Forane) (P): produces amnesia, muscle relaxant, hypnosis, not NOT analgesia- give narc. May cause vomiting, hypotension, and shivering post procedure.Watch for genetic malignant hyperthermia- tachycardia, fever,rigid muscles, acid/base dx
IV anesthetics: drug/action/cautions propofol (Diprivan) (P): avoid in soy and egg allergy; titrated slowly to produce hypnosis, amnesia, sedation for procedures. Irritating to veins
Local anesthetics: drug/action/cautions lidocaine (Xylocaine) (P), bupivicaine (Marcaine- for epidural): not to be given systemically. Numbs structures by blocking Na channels.
Local anesthetics routes Topical, infiltration- directly into site to be treated; field block- entire area procedure will occur (dentistry); nerve block- epidurals and intrathecal= spinal anesthesia- higher risk
Urinary analgesic drug/action/cautions phenazopyridine hydrochloride (Pyrimidine, AZO): passes thru and has analgesic effect on urinary tract to relieve pain, swelling, burning. Does not tx the UTI. Causes urine to be orange/red. Too much= yellow skin. Give with food, incr fluid intake
Benzodiazapine class/indications Anxiolytic and hypnotic. Used to decrease anxiety, ETOH withdrawal, muscle spasm, sleep aid, pre-op sedation, agitation by enhancing GABA receptors (decr. nerve excitability)
Benzo SE Anticholingeric: dry mouth, urinary retention, constipation, blurred vision; drowsiness, BP changes, anemia, phebitis, incr. liver enzymes
Benzos Cautions Always taper off- seizures (for withdrawal, antidote=flumazenil (Romazicon); decrease narc doses to prevent too much RR depression; give PO if possible; pt safety, psychosis in elderly, smaller dose in blacks
temazepam (Restoril) Sleep aid, situationally used
diazepam (Valium) anxiety, acute ETOH withdrawal, muscle spasm, seizures
lorazepam (Ativan) Pre-op, anxiety, procedural amnesia, rapid onset
midazolam (Versed) Produces amnesia for unpleasant procedures (colonoscopy, etc), induction of general anesthesia
chlordiazepoxide (Librium) Can be used before an anticipated ETOH withdrawal- do not give with grapefruit juice.
alprazolam (Xanax) anxiety, panic attacks
Non-benzos: chloral hydrate (Aqua Chloral) For children, prior to procedures, fairly safe
eszopiclone (Lunesta) Only drug approved for long-term sleep aid
zaleplon (Sonata) Short-term sleep aid
zolpidem (Ambien) Sleep aid; watch dose in elderly, similar to benzos
ramelteon (Rozerem) Melatonin receptor agonist drug- sleep aid; do not give with melatonin. No abuse potential
disulfiram (Antabuse) Maintains sobriety by producing severe nausea when ETOH is consumed. Opiate antagonists also help to decrease cravings
Narcotic antagonist action Block opiod receptors, reverse effects of respiratory depression and sedation. Reverses analgesia, increases HR and BP. May cause withdrawal. Short effect time. naloxone (Narcan)
Opiod agonist-antagonists (contain some Narcan) pentazocine (Talwin) (P) and nalbuphine (Nubain), Stadol. Analgesics with less abuse potential. May induce withdrawal in pts with narc addiction-dont give.for moderate-severe pain, anesthesia aid, childbirth
Opiod agonist-antagonist cautions Cardiac pts, narc abusers, labor. Increases BP and produces hallucinations. Watch- will interact with other CNS depressants
Adjuvant meds for pain control include TCA (amitryptiline/Elavil and imipramine/Tofranil), SNRIs (duloxetine/Cymbalta & velafaxine/Effexor), Anticonvulsants (pregabalin/Lyrica and gabapentin/Neurontin, and local anesthetics (lidocaine patch)
TCAs action/cautions as an adjuvant Increase NE & serotonin. Anticholinergic SE. Treats nerve pain/fibromyalgia. 2-3 wks to work. Sedating, take HS. Causes ortho.hypotnsn- watch cardiac pts
SNRIs as an adjuvant Blocks NE reuptake; No anticholinergic SE. Nerve pain/fibro. May change sleep habits, dizziness, sweating, tachycardia, HTN (d/t NE action)
Opiod agonists uses Severe acute or chronic pain, aid anesthesia, relieves perception of pain during diagnostic exams, nonbacterial abdominal cramps and diarrhea, pulmonary edema, severe unproductive cough, SOB/dyspnea
How do opiods treat pulmonary edema? It causes vasodilation in the periphery, causing blood to sit in extremities, decreasing preload to the heart and lungs. Decreases sensation of "suffocating" thru sedation too.
How do opioids treat a severe, unproductive cough? Decreases cough reflex by decreasing the brain's perceived need to cough
Opioid agonist cautions Allergy, pregnancy/lactation labor (crosses placenta), acute abdomen (do not give narcs-masks real problem), head injury (can depress function even further), respiratory depression, liver/kid. dx, prostatic hypertrophy- exacerbates urinary retention
Opiods AE Resp. depression, orthostatic hypotension (d/t vasodilation), decreased GI motility (N/V/C/biliary spasm), lightheadedness, dizzy, hallucinations, pupil constriction (pinpoint), slowed mentation, pruritus (not an allergy), urinary ret., sweating, dry mout
Nursing implications for Opioid agonists Hold med if RR <10, have emergency O2 and suction ready, tx pain without delay, give before therapy, smallest effective dose, monitor sedation, pt safety, monitor voiding/stool (also bowel program), teach pulm. hygiene- deep breathing. Nonnarc interventio
Cancer pts on opiods Treat breakthrough pain. Make sure you wake them up at night to give meds to keep therapeutic dose. Stay on schedule
Critically ill on opiods Small doses, watch RR.
tramadol (Ultram) A weaker narc for chronic pain. Can accumulate however
methadone (Dolophin) Used to substitute addictive substance during withdrawal
oxycodone (Roxicodone) Highly abused; immediate release, is a codeine derivative. oxycontin = ER, ppl tend to crush, snort this
hydrocodone (Vicodin, Lortab) Similar to codeine; CII drug
hydrocodone XL (Zohydro) An ER hydrocodone, given at 50 mg instead of usual 5 mg. Newer drug for chronic pain, pt is under contract to not abuse/overdose
hydromorphone (Dilaudid) Semi-synthetic morphine, very strong. Usually given by IV drip for cancer pts. Like morphine but much more potent
codeine Antitussive. Weaker than morphine, but often given with APAP. Usually PO in cough syrups
fentanyl (Sublimaze, Duragesic) Aids anesthesia, post-op, chronic pain. Given transmucosally (lollipop) or transdermally thru patch- 24 hr onset, lasts 3 days (dispose of in needle container) Heat sensitive
meperidine hydrochloride (Demerol) Shorter duration than morphine, less resp. depression in newborn (good for childbirth), less smooth muscle spasm (renal/biliary colic- pts w stones), little to no effect if PO.Contraindicated in renal failure.Has toxic limit
morphine (Roxanol) (P) Severe acute or chronic pain, a nonceiling drug. PO doses must be higher d/t first pass effect. IM, IV, Subcut, R, epidural, intrathecal all possible routes. May produce renal, biliary colic
Priorities during overdose Airway (Fowler's position, O2 mask on), Breathing, Circulation. Give opioid antagonist- nalaxone/Narcan. Taper doses, substitute methadone in place of addictive substance, then slowly withdraw.
S/S of withdrawal syndrome Pupil dilation, A/N/V/D, increased temp, HR, BP, diaphoresis, restlessness, anxiety, rhinorrhea. Peak = 36-72 hrs after last dose, declines over 10 days. In infants- inconsolable cry, have a high mortality rate
Ladder of Analgesia 1= nonopioids, give for cancer and chronic pain at first, 2= opioids for mild to mod pain, 3= opioids for mod to severe pain, start acute pain here. 4= nerve blocks, PCA, etc for surgical procedures, then move down.
Types of nociceptive pain Visceral- response to inflammation, ischemia, or stretch- often poorly localized- referred pain. Somatic- superficial or deep, more receptors- more localized
Examples of neuropathic pain Deafferentation: loss of sensory input d/t peripheral nerve injury(ex. phantom limb), central pain: lesion in CNS- irritated nerve tracts; sympathetically maintained: dysregulated ANS circuit; Peripheral neuropathy-nerve dam. (diabetes)
Mechanisms of pain perception Transduction, Transmission, Perception, Modulation
Migraine drug categories Ergotamine derivatives, Triptans (selective serotonin 5-HT receptor agonists)
Migraine pathogenesis Trigger- lights, caffeine, weather, foods, hormonal changes, stress, noise, fatigue, sleep deprivation, hunger, ETOH. -> neuronal hypersensitivity releases vasoactive enzymes-> dilation/plasma proteins-> inflam-> migraine
Types of HA/migraine Cluster- behind eye; sinus- cheekbones, above eyes; TMJ- temples, in front of ears; tension- band around head; neck- back of head, neck; migraine- all over, throbbing, N, vision changes, sensitivity to stimuli
Triptans (selective serotonin 5-HT receptor agonists) zolmitriptan (Zomig), sumatriptan (Imitrex (P)); ABORTIVE AGENT. Binds serotonin receptors- produces vasoconstriction for acute tx.Is not selective for which vessels-> caution in HTN, CAD, PVD, and pregnancy! watch circulation. Do not combine with ergots!
Daily preventative meds for migraine topiramate (Topamax), valproic acid, gabapentin (Neurontin)
Ergot derivatives ergotamine tartrate (Ergomar) (P): abortive agent, take at first sign. SL or inhalation; caution in PVD, CAD, HTN, pregnancy. (produces vasoconstriction), not for prolonged use, watch circulation in extremities. may contain caffeine
Ergotism S/S Produced by overdose- N/V, thirst, chest pain, BP increases drastically.
OTC Migraine meds Often contain ASA/APAP/caffeine (potentiates drug), like Excedrin HA
Anti-gout drug categories Urocosuric agent, Xanthine Oxidase Inhibitors/urocosuric agent, Antigout agent/alkaloid
Urocosuric agent Probenecid (only name); increases excretion of uric acid via kidneys. Is contraindicated in renal/liver dx. Teach to alkalinize urine to throw out more acid, No ETOH or ASA, increase fluid intake
Urocosuric agent AE/Cautions Caution: Sulpha allergy, contraindicated in renal or liver dx. AE= n/v, liver necrosis, hyperglycemia (watch diabetics). No ETOH or ASA
Xanthine Oxidase Inhibitor/Urocosuric Agent allopurinol (Zyloprim) (P): decreases serum uric acid as a byproduct. Often used to prevent gout in cancer pts (increased # of dying cells release uric acid); effective in chronic gout w/ tophi and decr. renal fxn. Mobilizes -> acute gout attack
Xanth. Oxidase inhibitor considerations Watch UO. Acute gout attack may occur as tophi are mobilized, could cause stones. drink adequate fluids to support renal fxn. May suppress BM. Monitor UA and CBC
Antigout agent/alkaloid colchicine (Colcrys) (P)- for ACUTE GOUT. Decreases WBC diapedesis into cells with crystals- reduces inflammation, pain, swelling.
Antigout agent/alkaloid precautions Doesn't tx gout, just inflammation. Reduce elderly dose, renal, liver dz. Do not take with grapefruit juice, ETOH- affects liver enzyme pathways. AR= N/V/BM suppression, neuropathy from decreased B12 absorption
4 stages of gout 1. asymptomatic hyperuricemia, 2. acute flares, 3 inter critical gout, 4. advanced gout. May be d/t decreased metabolism/excretion of UA, kidney probe, diet, dehydration
Nonnarcotic Analgesic Antipyretic acetaminophen (Tylenol) (APAP) (P): ASA substitute as does not cause GI distress or bleeding; Choice for children d/t ASA causing Reyes.
APAP Cautions May produce liver necrosis esp with ETOH, cigs, antiseizure drugs. Overdose= N/V/A/sweating/elevated LFTs/jaundice/delirium/nephrotoxicity as kidneys try to flush out. Rx= gastric lavage w/ activated charcoal. Antidote= Mucomyst (acetylcysteine)
APAP laws FDA says tabs can contain no more than 325 mg with mixed drugs). Safe dose = 4g, 2g in liver dz. Tylenol advises <3g/day. Watch for APAP in other meds to avoid overdose
indomethacin (Indocin) (P) Acetic acid derivative, stronger than ibuprofen but higher risk of geriatric SE like CVA/MI. give less. Treats arthritis and gout- stronger anti-inflammatory effects. Also txs ductus arteriosus in neonates.
ketorolac (Toradol) acetic acid deriv. For pain control, comparable to morphine. Strong analgesic and antiinflamm; may produce hematoma and wound bleeding, decr. healing if parenteral dose > 5 days. Used after ortho surg. Watch GI- risk for perforation
ibuprofen (Motrin) (P) propionic acid deriv. Txs inflamm., fever, pain, arthritis, gout. Potentially nephrotoxic and hepatotoxic. Allergy more common in pts w/ hx of rhinitis and asthma. (NSAIDs cause bronchoconstriction). Includes naproxen (Aleve) and Advil
AE of ibuprofen
Cautions for all NSAIDS Do not give to asthmatics (bronchoconstriction); cause gastric irritation and renal impairment- watch BUN and creatinine. Stop NSAIDs 1 wk preop d/t anti-PLT effect.
Salicylates aspirin/acetylsalicyclic acid (P) txs mod to severe pain, fever, prevents MI/CVA at low dose daily therapy. do not take for 2 wks preop. Take with food and adequate fluids to support renal. Avoid ASA w/ tartrazine. No caffeine
Salicylism SE N/V/fever/TINNITUS/drowsiness, hyperventilation, respiratory alkalosis, metabolic acidosis, hemorrhage, seizures
Tx of salicylism Mild: stop/reduce dose; Severe: activated charcoal, IV sodium bicarbonate to increase renal elimination, hemodialysis.
Interactions of ASA/NSAIDs Increased effect with ETOH, narcs, anticoagulants.
AE of ASA/NSAIDs Ulcers, A/N/V/bleeding-misoprostol (Cytosec); melena, bruising, hematuria; HA/dizziness, confusion. Hypersensitivity- asthmatics-> bronchospasm. Tinnitus and hearing loss, nephrotoxic: decr. UO, increased BUN, creatinine, hyperkalem, fluid retent, edema
ASA/NSAIDs contraindications Impaired renal fxn, asthma, allergy, peptic ulcer dz, GI bleeding, children with viral infxn-> Reye's syndrome-- encephalopathy, blindness, LOC change, confusion. Use tylenol instead.
ASA and NSAID effect on PLTs Both inhibit PLT aggregation (anticoags only affect clotting factors), ASA- immediate and permanent effect on PLTs (whole life span); NSAIDs- limited effect only while drug is in system. Just enough to keep clots from forming, blood moving around
Antiprostaglandins Includes ASA (salicylates), NSAIDs and APAP, although APAP is not antiinflammatory. ASA = (P). Classes= Non-selective COX inhibitors and Selective COX-2 inhibitors
Non-selective COX inhibitors Block both COX 1 and 2 (cyclooxygenase, precursor to prostas)- inhibit both physiological and pathological actions of prostas- includes NSAIDs and ASA
Selective COX-2 inhibitors Inhibits pathologic effects of prostaglandins- inflammation, pain, vasodilation, swelling (increased capillary permeability), leukocytosis and inflamm. cytokines
Physiologic effects of prostas (blocked by Non-selective COX inhibitors) GI protection- increased mucus production, decreased acid production, GI mucosal perfusion; Renal protection- perfusion, fxn; relaxes smooth muscle tone- bronchodilation, vasodilation; regulates PLT aggregation
Effects of Non-selective COX inhibitors blocking physiological pathway GI ulcers, bleeding, impaired renal fxn, bronchoconstriction, decreased PLT aggregation
Selective COX-2 Inhibitor drug and indications celecoxib (Celebrex) (P)- only for pts for which non-selective don't work, kidney dz, GI ulcers; only approved for short term use (couple months) d/t increased risk for CVA, MI, visual changes. Rx only.