Syndrome of CNS dysfunction  Most common chronic neurologic illness  Results from excessive electrical activity of neurons located in superficial area of brain (gray matter)

Brief episode of abnormal electrical activity in nerve cells of the brain

Involuntary spasmodic contractions of any or all voluntary muscles throughout the body, including skeletal, facial, and ocular muscles

Multiple seizures occur with no recovery between them.  Result: hypotension, hypoxia, brain damage, and death  True medical emergency

Medications that relieve pain without causing loss of consciousness  “Painkillers”  Opioid analgesics  Adjuvant analgesic drugs

Pain results from stimulation of sensory nerve fibers called nociceptors.  These receptors transmit pain signals from various body regions to the spinal cord and brain.

Level of stimulus needed to produce the perception of pain  A measure of the physiologic response of the nervous system

Assist primary drugs in relieving pain  NSAIDs  Antidepressants  Anticonvulsants  Corticosteroids

relieve pain  Mild agonists: codeine, hydrocodone  Strong agonists: morphine, hydromorphone, oxycodone, meperidine, fentanyl, and methadone

not recommended for long-term use because of the accumulation of a neurotoxic metabolite, normeperidine, which can cause seizures

Opioid Ceiling Effect

Drug reaches a maximum analgesic effect.  Analgesia does not improve, even with higher doses.  Pentazocine  Nalbuphine

Bind to an opioid pain receptor in the brain  Cause an analgesic response (reduction of pain sensation)

Bind to a pain receptor  Cause a weaker neurologic response than a full agonist  Also called partial agonist or mixed agonist

Reverse the effects of these drugs on pain receptors  Bind to a pain receptor and exert no response  Also known as competitive antagonists

Ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration that provide comparable analgesia  Hydromorphone (Dilaudid): seven times more potent than morphine

Opioid Analgesics: Contraindications

Severe asthma  Use with extreme caution in patients with:  Respiratory insufficiency  Elevated intracranial pressure  Morbid obesity or sleep apnea  Paralytic ileus

Opioid Analgesics: Adverse Effects

CNS depression  Leads to respiratory depression  Most serious adverse effect  Nausea and vomiting  Urinary retention  Diaphoresis and flushing  Pupil constriction (miosis)  Constipation

Opioid Analgesics: Toxicity and Management of Overdose

Naloxone (Narcan)  Naltrexone (ReVia)  Regardless of withdrawal symptoms, when a patient experiences severe respiratory depression, an opioid antagonist should be given.

opioid withdrawal or opioid abstinence syndrome manifestations

Anxiety, irritability, chills and hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramps, diarrhea, confusion

Opioid Analgesics: Interactions

Alcohol  Antihistamines  Barbiturates  Benzodiazepines  Monoamine oxidase inhibitors

Opioid agonist  Natural opiate alkaloid (Schedule II) obtained from opium  Less effective  Ceiling effect  Often combined with acetaminophen

Synthetic opioid (Schedule II) used to treat moderate to severe pain  Parenteral injections, transdermal patches (Duragesic), buccal lozenges (Fentora), and buccal lozenges on a stick (Actiq), long term pain

Hydromorphone (Dilaudid)

very potent opioid analgesic; Schedule II drug

Caution with those with kidney dysfunction  Active metabolite (normeperidine) can accumulate to toxic levels and cause seizures  Rarely used and not recommended for long-term pain treatment  Use:  Migraine treatment  Post-op shivering

Methadone Hydrochloride

Synthetic opioid analgesic (Schedule II)  Opioid of choice for the detoxification treatment of opioid addicts in methadone maintenance programs  Prolonged half-life of the drug: cause of unintentional overdoses and deaths  Cardiac dysrhythmias

Naturally occurring alkaloid derived from the opium poppy  Drug prototype for all opioid drugs; Schedule II controlled substance  Indication: severe pain  High abuse potential

Opioid Agonists- Antagonists

Buprenorphine (Buprenex)  Butorphanol (Stadol)  Nalbuphine (Nubain)  Pentazocine (Talwin)

Naloxone Hydrochloride (Narcan)

Pure opioid antagonist  Drug of choice for the complete or partial reversal of opioid-induced respiratory depression  Indicated in cases of suspected acute opioid overdose

Opioid antagonist  Oral form  Used for alcohol and opioid addiction

Nonopioid Analgesics: Acetaminophen

Analgesic and antipyretic effects  Little to no antiinflammatory effects  Available over-the-counter (OTC) and in combination products with opioids

Acetaminophen: Dosage

Maximum daily dose for healthy adults is being lowered to 3000 mg/day.  2000 mg for older adults and those with liver disease

Acetaminophen: Contraindications and Interactions

Should not be taken in the presence of:  Drug allergy  Liver dysfunction  Possible liver failure  G6PD deficiency  Dangerous interactions may occur if taken with alcohol

Acetaminophen: Toxicity and Managing Overdose

Recommended antidote: acetylcysteine regimen. whether intentional or resulting from chronic unintentional misuse, causes hepatic necrosis: hepatotoxicity

Tramadol Hydrochloride

Centrally acting analgesic with a dual mechanism of action  Weak bond to mu opioid receptors  Inhibits the reuptake of norepinephrine and serotonin

Lidocaine, transdermal

topical anesthetic  Indications: postherpetic neuralgia  Left in place no longer than 12 hours  Minimal adverse effects  Skin irritation may occur

Herbal Products: Feverfew

Related to the marigold family  Antiinflammatory properties  Used to treat migraine headaches, menstrual cramps, inflammation, and fever  May cause GI distress, altered taste, muscle stiffness  May interact with aspirin and other NSAIDs

transient, reversible, and periodic state of rest ◦ Decrease in physical activity and consciousness Normal sleep is cyclic and repetitive. A sleeping person is unaware of sensory stimuli within the immediate environment.

CNS Depressants: Benzodiazepines

Formerly the most commonly prescribed sedative- hypnotic drugs Nonbenzodiazepines are currently more frequently prescribed. Favorable adverse effect profiles, efficacy, and safety when used appropriately

Benzodiazepines: Mechanism of Action

Depress CNS activity Affect hypothalamic, thalamic, and limbic systems of the brain Benzodiazepine receptors ◦ Gamma-aminobutyric acid (GABA) Do not suppress rapid eye movement (REM) sleep as much as barbiturates do

Benzodiazepines: Contraindications

Drug allergy Narrow-angle glaucoma Pregnancy

Benzodiazepines: Adverse Effects

Headache ◦ Drowsiness ◦ Dizziness ◦ Cognitive impairment ◦ Vertigo ◦ Lethargy ◦ Fall hazard for older adults ◦ “Hangover” effect

Benzodiazepines: Toxicity and Overdose

Somnolence Confusion Coma Diminished reflexes Do not cause hypotension and respiratory depression unless taken with other CNS depressants Flumazenil as an antidote

Benzodiazepines: Interactions

Azole antifungals, verapamil, diltiazem, protease inhibitors, macrolide antibiotics, grapefruit juice CNS depressants (alcohol, opioids) Olanzapine Rifampin Herbal Interactions

Herbal Products: Kava

relieve anxiety, stress, and restlessness and to promote sleep May cause temporary yellow skin discoloration (extended, continued intake) and visual disturbances Potential interactions with alcohol, barbiturates, and psychoactive drugs, dont drive

Nonbenzodiazepine: Zolpidem (Ambien)

Short-acting nonbenzodiazepine hypnotic Lower incidence of daytime sleepiness compared with benzodiazepine hypnotics Ambien CR is a longer acting form with two separate drug reservoirs. Somnambulation

relieve pain associated with skeletal muscle spasms Majority are centrally acting. ◦ CNS is the site of action. ◦ Similar in structure and action to other CNS depressants Direct acting ◦ Act directly on skeletal muscle ◦ Closely resemble GABA

Muscle Relaxants: Adverse Effects

Euphoria ◦ Lightheadedness ◦ Dizziness ◦ Drowsiness ◦ Fatigue ◦ Muscle weakness

Toxicity and Management of Overdose muscle relaxants

No specific antidote or reversal Best treated with conservative supportive measures If taken along with other CNS depressants ◦ Adequate airway must be maintained ◦ EKG monitoring ◦ Fluid management to avoid crystalluria

Common Muscle Relaxants

Baclofen (Lioresal) Cyclobenzaprine (Flexeril) Dantrolene (Dantrium) Metaxalone (Skelaxin) Tizanidine (Zanaflex) Carisoprodol (Soma) Chlorzoxazone (Paraflex) Methocarbamol (Robaxin)

Oral and injectable forms Treat chronic spastic muscular conditions ◦ Implantable baclofen pump device

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Question	Answer
Epilepsy	Syndrome of CNS dysfunction  Most common chronic neurologic illness  Results from excessive electrical activity of neurons located in superficial area of brain (gray matter)
Seizure	Brief episode of abnormal electrical activity in nerve cells of the brain
Convulsion	Involuntary spasmodic contractions of any or all voluntary muscles throughout the body, including skeletal, facial, and ocular muscles
Status Epilepticus	Multiple seizures occur with no recovery between them.  Result: hypotension, hypoxia, brain damage, and death  True medical emergency
Analgesics	Medications that relieve pain without causing loss of consciousness  “Painkillers”  Opioid analgesics  Adjuvant analgesic drugs
Nociception	Pain results from stimulation of sensory nerve fibers called nociceptors.  These receptors transmit pain signals from various body regions to the spinal cord and brain.
Pain Threshold	Level of stimulus needed to produce the perception of pain  A measure of the physiologic response of the nervous system
Adjuvant Drugs	Assist primary drugs in relieving pain  NSAIDs  Antidepressants  Anticonvulsants  Corticosteroids
Opioid Drugs	relieve pain  Mild agonists: codeine, hydrocodone  Strong agonists: morphine, hydromorphone, oxycodone, meperidine, fentanyl, and methadone
 Meperidine	not recommended for long-term use because of the accumulation of a neurotoxic metabolite, normeperidine, which can cause seizures
Opioid Ceiling Effect	Drug reaches a maximum analgesic effect.  Analgesia does not improve, even with higher doses.  Pentazocine  Nalbuphine
Agonists	Bind to an opioid pain receptor in the brain  Cause an analgesic response (reduction of pain sensation)
Agonists-Antagonists	Bind to a pain receptor  Cause a weaker neurologic response than a full agonist  Also called partial agonist or mixed agonist
Antagonists	Reverse the effects of these drugs on pain receptors  Bind to a pain receptor and exert no response  Also known as competitive antagonists
Equianalgesia	Ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration that provide comparable analgesia  Hydromorphone (Dilaudid): seven times more potent than morphine
Opioid Analgesics: Contraindications	Severe asthma  Use with extreme caution in patients with:  Respiratory insufficiency  Elevated intracranial pressure  Morbid obesity or sleep apnea  Paralytic ileus
Opioid Analgesics: Adverse Effects	CNS depression  Leads to respiratory depression  Most serious adverse effect  Nausea and vomiting  Urinary retention  Diaphoresis and flushing  Pupil constriction (miosis)  Constipation
Opioid Analgesics: Toxicity and Management of Overdose	Naloxone (Narcan)  Naltrexone (ReVia)  Regardless of withdrawal symptoms, when a patient experiences severe respiratory depression, an opioid antagonist should be given.
opioid withdrawal or opioid abstinence syndrome manifestations	Anxiety, irritability, chills and hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramps, diarrhea, confusion
Opioid Analgesics: Interactions	Alcohol  Antihistamines  Barbiturates  Benzodiazepines  Monoamine oxidase inhibitors
Codeine Sulfate	Opioid agonist  Natural opiate alkaloid (Schedule II) obtained from opium  Less effective  Ceiling effect  Often combined with acetaminophen
Fentanyl	Synthetic opioid (Schedule II) used to treat moderate to severe pain  Parenteral injections, transdermal patches (Duragesic), buccal lozenges (Fentora), and buccal lozenges on a stick (Actiq), long term pain
Hydromorphone (Dilaudid)	very potent opioid analgesic; Schedule II drug
Meperidine	Caution with those with kidney dysfunction  Active metabolite (normeperidine) can accumulate to toxic levels and cause seizures  Rarely used and not recommended for long-term pain treatment  Use:  Migraine treatment  Post-op shivering
Methadone Hydrochloride	Synthetic opioid analgesic (Schedule II)  Opioid of choice for the detoxification treatment of opioid addicts in methadone maintenance programs  Prolonged half-life of the drug: cause of unintentional overdoses and deaths  Cardiac dysrhythmias
Morphine Sulfate	Naturally occurring alkaloid derived from the opium poppy  Drug prototype for all opioid drugs; Schedule II controlled substance  Indication: severe pain  High abuse potential
Opioid Agonists- Antagonists	Buprenorphine (Buprenex)  Butorphanol (Stadol)  Nalbuphine (Nubain)  Pentazocine (Talwin)
Naloxone Hydrochloride (Narcan)	Pure opioid antagonist  Drug of choice for the complete or partial reversal of opioid-induced respiratory depression  Indicated in cases of suspected acute opioid overdose
Naltrexone	Opioid antagonist  Oral form  Used for alcohol and opioid addiction
Nonopioid Analgesics: Acetaminophen	Analgesic and antipyretic effects  Little to no antiinflammatory effects  Available over-the-counter (OTC) and in combination products with opioids
Acetaminophen: Dosage	Maximum daily dose for healthy adults is being lowered to 3000 mg/day.  2000 mg for older adults and those with liver disease
Acetaminophen: Contraindications and Interactions	Should not be taken in the presence of:  Drug allergy  Liver dysfunction  Possible liver failure  G6PD deficiency  Dangerous interactions may occur if taken with alcohol
Acetaminophen: Toxicity and Managing Overdose	Recommended antidote: acetylcysteine regimen. whether intentional or resulting from chronic unintentional misuse, causes hepatic necrosis: hepatotoxicity
Tramadol Hydrochloride	Centrally acting analgesic with a dual mechanism of action  Weak bond to mu opioid receptors  Inhibits the reuptake of norepinephrine and serotonin
Lidocaine, transdermal	topical anesthetic  Indications: postherpetic neuralgia  Left in place no longer than 12 hours  Minimal adverse effects  Skin irritation may occur
Herbal Products: Feverfew	Related to the marigold family  Antiinflammatory properties  Used to treat migraine headaches, menstrual cramps, inflammation, and fever  May cause GI distress, altered taste, muscle stiffness  May interact with aspirin and other NSAIDs
Sleep	transient, reversible, and periodic state of rest ◦ Decrease in physical activity and consciousness Normal sleep is cyclic and repetitive. A sleeping person is unaware of sensory stimuli within the immediate environment.
CNS Depressants: Benzodiazepines	Formerly the most commonly prescribed sedative- hypnotic drugs Nonbenzodiazepines are currently more frequently prescribed. Favorable adverse effect profiles, efficacy, and safety when used appropriately
Benzodiazepines: Mechanism of Action	Depress CNS activity Affect hypothalamic, thalamic, and limbic systems of the brain Benzodiazepine receptors ◦ Gamma-aminobutyric acid (GABA) Do not suppress rapid eye movement (REM) sleep as much as barbiturates do
Benzodiazepines: Contraindications	Drug allergy Narrow-angle glaucoma Pregnancy
Benzodiazepines: Adverse Effects	Headache ◦ Drowsiness ◦ Dizziness ◦ Cognitive impairment ◦ Vertigo ◦ Lethargy ◦ Fall hazard for older adults ◦ “Hangover” effect
Benzodiazepines: Toxicity and Overdose	Somnolence Confusion Coma Diminished reflexes Do not cause hypotension and respiratory depression unless taken with other CNS depressants Flumazenil as an antidote
Benzodiazepines: Interactions	Azole antifungals, verapamil, diltiazem, protease inhibitors, macrolide antibiotics, grapefruit juice CNS depressants (alcohol, opioids) Olanzapine Rifampin Herbal Interactions
Herbal Products: Kava	relieve anxiety, stress, and restlessness and to promote sleep May cause temporary yellow skin discoloration (extended, continued intake) and visual disturbances Potential interactions with alcohol, barbiturates, and psychoactive drugs, dont drive
Nonbenzodiazepine: Zolpidem (Ambien)	Short-acting nonbenzodiazepine hypnotic Lower incidence of daytime sleepiness compared with benzodiazepine hypnotics Ambien CR is a longer acting form with two separate drug reservoirs. Somnambulation
Muscle Relaxants	relieve pain associated with skeletal muscle spasms Majority are centrally acting. ◦ CNS is the site of action. ◦ Similar in structure and action to other CNS depressants Direct acting ◦ Act directly on skeletal muscle ◦ Closely resemble GABA
Muscle Relaxants: Adverse Effects	Euphoria ◦ Lightheadedness ◦ Dizziness ◦ Drowsiness ◦ Fatigue ◦ Muscle weakness
Toxicity and Management of Overdose muscle relaxants	No specific antidote or reversal Best treated with conservative supportive measures If taken along with other CNS depressants ◦ Adequate airway must be maintained ◦ EKG monitoring ◦ Fluid management to avoid crystalluria
muscle relaxants interactions	Benzodiazepines ◦ Alcohol
Common Muscle Relaxants	Baclofen (Lioresal) Cyclobenzaprine (Flexeril) Dantrolene (Dantrium) Metaxalone (Skelaxin) Tizanidine (Zanaflex) Carisoprodol (Soma) Chlorzoxazone (Paraflex) Methocarbamol (Robaxin)
Baclofen (Lioresal)	Oral and injectable forms Treat chronic spastic muscular conditions ◦ Implantable baclofen pump device
Cyclobenzaprine (Flexeril)	Oral and extended release oral form (Amrix) Centrally acting muscle relaxer Most common used muscle relaxer Can cause marked sedation
Antiepileptic Drugs (AEDs)	Also known as anticonvulsants  Goals of therapy  To control or prevent seizures while maintaining a reasonable quality of life  To minimize adverse effects and drug-induced toxicity  AED therapy is usually lifelong
Antiepileptic Drugs (Cont.)	Single-drug therapy is started before multiple- drug therapy is tried.  Serum drug concentrations must be measured.  Therapeutic drug monitoring
Antiepileptic drugs traditionally used to	manage seizure disorders include:  Barbiturates  Hydantoins  Iminostilbenes plus valproic acid  Second- and third-generation antiepileptics
Antiepileptic Drugs: Indications	Prevention or control of seizure activity  Long-term maintenance therapy for chronic, recurring seizures  Acute treatment of convulsions and status epilepticus
Antiepileptic Drugs: Adverse Effects	Black box warning as of 2008  Suicidal thoughts and behavior  Long-term therapy with phenytoin (Dilantin) may cause gingival hyperplasia, acne, hirsutism, and Dilantin facies.
Antiepileptic Drugs: Interactions	Induce hepatic metabolism resulting in reduction of effects of other drugs.  Interfere with birth control.  Avoid grapefruit with carbamazepine.
Antiepileptic Drug Listing	Valproic acid  Gabapentin (Neurontin)  Lamotrigine (Lamictal)  Felbamate (Felbatol)  Levetiracetam (Keppra)  Topiramate (Topamax)  Zonisamide (Zonegran)  Tiagabine (Gabitril)
Barbiturates: Phenobarbital and Primidone (Mysoline)	Primidone is metabolized in the liver to phenobarbital.  Most common adverse effect: sedation  Therapeutic effects: serum drug levels of 10 to 40 μg/mL
barbiturates: Phenobarbital and Primidone (Mysoline) effects	Contraindications: known drug allergy, porphyria, liver or kidney impairment, and respiratory illness  Adverse effects: cardiovascular, CNS, gastrointestinal (GI), and dermatologic reactions
Hydantoins: Phenytoin (Dilantin)	Phenytoin (Dilantin) has been used as a first-line drug for many years and is the prototypical drug.  Adverse effects: gingival hyperplasia, acne, hirsutism, Dilantin facies, and osteoporosis  Therapeutic drug levels are usually 10 to 20 μg/mL.
Hydantoins: Phenytoin (Dilantin) (Cont.)	intravenous (IV) administration  Very irritating to veins  Slow IV directly into a large vein through a large- gauge (20-gauge or larger) venous catheter  Diluted in normal saline (NS) for IV infusion  Filter must be used.  Saline flush
Hydantoins: Fosphenytoin (Cerebyx)	Injectable prodrug of phenytoin  Water-soluble phenytoin derivative that can be given intramuscularly or intravenously—by IV push or continuous infusion—without causing burning on injection associated with phenytoin
Iminostilbenes: Carbamazepine (Tegretol)	Second most commonly prescribed antiepileptic drug in the United States after phenytoin  Autoinduction of hepatic enzymes
Oxcarbazepine (Trileptal)	Chemical analogue of carbamazepine  Precise mechanism of action has not been identified.  For partial seizures and secondarily generalized seizures  Adverse reactions  Headache, dizziness, nausea
Ethosuximide (Zarontin)	Used in the treatment of uncomplicated absence seizures  Not effective for secondary generalized tonic-clonic seizures  Contraindication: known allergy  Adverse effects: GI and CNS effects  Drug interactions: hepatic enzyme–inducing drugs
Gabapentin (Neurontin)	Chemical analogue of GABA, a neurotransmitter that inhibits brain activity  Treatment of partial seizures  Most often used for treatment of neuropathy  Contraindication: known drug allergy  Adverse effects: CNS and GI symptoms
Lamotrigine (Lamictal)	Also used for the treatment of bipolar disorder  Used for simple or complex partial seizures  Contraindications: drug allergy  Common adverse effects: relatively minor CNS and GI symptoms and possible Stevens-Johnson syndrome
Levetiracetam (Keppra)	Adjunct therapy for partial seizures with and without secondary generalization  Contraindication: known drug allergy  Mechanism of action: unknown  Adverse effects: generally well tolerated, CNS
Pregabalin (Lyrica)	Indication: adjunct therapy for partial seizures  Most common uses: neuropathic pain, postherpetic neuralgia, and fibromyalgia  Contraindication: known drug allergy  Adverse drug reactions: primarily CNS related
Tiagabine (Gabitril)	partial seizures  Mechanism of action has not been identified.  Beneficial effects by inhibiting the reuptake of GABA  Avoid off label use of this drug as it can cause paradoxical seizures.  Adverse effects: CNS and GI symptoms
Topiramate (Topamax)	Adjunct therapy for partial and secondarily generalized seizures, for generalized tonic-clonic seizures, and for drop attacks in Lennox-Gastaut syndrome  Mechanism of action unknown  Adverse effects: CNS relate, angle-closure glaucoma
Valproic Acid	Treatment of generalized seizures, bipolar disorder, and controlling partial seizures  Highly protein bound  Adverse effects: drowsiness, GI disturbances, tremor, weight gain, hair loss, hepatotoxicity, pancreatitis
Three main emotional and mental disorders	Anxiety Affective disorders Psychoses
Anxiolytic Drugs	Reduce anxiety by reducing overactivity in central nervous system (CNS). Benzodiazepines  Depress activity in the brainstem and limbic system.
buspirone (Buspar)	Nonsedating and nonhabit forming  May have drug interaction with selective serotonin reuptake inhibitors
Benzodiazepines	Largest and most commonly prescribed anxiolytic Used to treat alcohol withdrawal, insomnia, and muscle spasms as well as adjunct for depression Alprazolam (Xanax) Diazepam (Valium) Lorazepam (Ativan)
Benzodiazepines: Adverse Effects	decreased CNS activity, sedation Hypotension Drowsiness, loss of coordination, dizziness, headaches Nausea, vomiting, dry mouth, constipation
Benzodiazepines: Overdose	Flumazenil (Romazicon) may be used to reverse benzodiazepines’ effects.
Benzodiazepines: Interactions	Alcohol and CNS depressants can result in additive CNS depression and even death. More likely to occur in patients with renal or hepatic compromise
Alprazolam (Xanax)	Indicated for GAD, short-term relief of anxiety symptoms, panic disorder, and anxiety associated with depression Adverse effects: confusion, ataxia, headache, and others Interactions: alcohol, oral contraceptives
Diazepam (Valium)	Long-acting benzodiazepine for relief of anxiety, management of alcohol withdrawal, reversal of status epilepticus, preoperative sedation, and relief of skeletal muscle spasms Avoid in hepatic dysfunction AE-headache, confusion, slurred speech
Lorazepam (Ativan)	Continuous infusion for agitated patients who are undergoing mechanical ventilation Used to treat or prevent alcohol withdrawal
Lithium	Drug of choice for the treatment of mania
Lithium adverse effects	Most serious adverse effect is cardiac dysrhythmia. Other effects: drowsiness, slurred speech, epilepsy- type seizures, choreoathetotic movements (involuntary wavelike movements of the extremities), ataxia
Antidepressant Drugs indications	Dysthymia (chronic low-grade depression) As adjunct for schizophrenia Eating disorders Personality disorders Various medical conditions
Antidepressants	Requires at least 6 weeks of therapy with adequate doses to be able to fully evaluate results May require upward titration of dosages over several weeks Should be used in conjunction with psychotherapy
Second-generation antidepressants	SSRIs Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Tricyclic Antidepressants (TCA)	Considered second line For patients who fail with SSRIs or other newer generation antidepressants As adjunct therapy with newer generation antidepressants Amitriptyline (Elavil)
Tricyclic Antidepressants: Mechanism of Action	Block reuptake of neurotransmitters, causing accumulation at the nerve endings It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression.
Tricyclic Antidepressants: Indications	Depression Childhood enuresis (imipramine) OCDs (clomipramine) Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia Increased appetite is an effect of TCAs
tricyclic Antidepressants: Adverse Effects	Sedation Impotence Orthostatic hypotension Others Older patients Dizziness, postural hypotension, constipation, delayed
Amitriptyline (Elavil)	Commonly used to treat insomnia and neuropathic pain Contraindications: known drug allergy, pregnancy, and recent myocardial infarction Adverse effects: dry mouth, constipation, blurred vision, urinary retention, and dysrhythmias
Herb commonly used for anxiety or depression:	St. John’s wort “Herbal Prozac”
Monoamine Oxidase Inhibitors (MAOIs)	Nonselective: isocarboxazid, phenelzine, and tranylcypromine Selective: selegiline Rarely used for depression Used for Parkinson’s disease Disadvantage: potential to cause hypertensive crisis when taken with tyramine
MAOIs and Tyramine	Ingestion of foods or drinks with tyramine leads to hypertensive crisis Avoid foods tyramine!
foods tyramine!	Aged, mature cheeses (cheddar, bleu, Swiss) Smoked, pickled, or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) Yeast extracts
Selegiline Transdermal Patch (Emsam)	Selective MAO-B inhibitor Indicated for major depression Contraindication includes known drug allergy. Adverse drug effects Avoid exposing the patch to external sources of heat or prolonged direct sunlight because heat speeds absorption
Second-Generation Antidepressants	Vortioxetine (Brintellix) Fewer adverse effects than TCAs and MAOIs Very few drug–drug or drug–food interactions Still take about 4 to 6 weeks to reach maximum clinical effectiveness
Second-Generation Antidepressants effects	insomnia (partly caused by reduced rapid eye movement sleep), weight gain, and sexual dysfunction
Second-Generation Antidepressants: Serotonin Syndrome symptoms	Delirium Agitation Tachycardia Sweating Myoclonus (muscle spasms) Hyperreflexia Shivering Course tremors
second-Generation Antidepressants: Serotonin Syndrome severe symptoms	Hyperthermia Seizures Rhabdomyolysis Renal failure Cardiac dysrhythmias Disseminated intravascular coagulation
Bupropion	Originally indicated for treatment of depression; now also indicated as an aid in smoking cessation  Sometimes added as an adjunct antidepressant for patients experiencing sexual adverse effects secondary to SSRI therapy
Zyban	approved for smoking cessation treatment and was the first nicotine-free prescription medicine used to treat nicotine dependence
Citalopram (Celexa)	One of the most commonly used SSRIs  Treatment of depression and OCD  Discontinuation syndrome  Adverse effects: anxiety, dizziness, drowsiness, insomnia
Duloxetine (Cymbalta)	Serotonin-norepinephrine reuptake inhibitor (SSNRI)  Indications: depression, GAD, and pain resulting from diabetic peripheral neuropathy or fibromyalgia  Adverse effects: dizziness, drowsiness, headache, GI upset, anorexia, and hepatotoxicity
Levomilnacipran (Fetzima)	Newest SSNRI approved  Side effects: hyperhidrosis, tachycardia, urinary retention
Fluoxetine (Prozac)	Prototypical SSRI  Indications: depression, bulimia, OCD, panic disorder, and premenstrual dysphoric disorder  Contraindications: known drug allergy and concurrent MAOI therapy  Adverse effects: anxiety, dizziness, drowsiness, insomnia
Mirtazapine (Remeron)	Promotes the presynaptic release of serotonin and norepinephrine in the brain  Sedation often occurs  Dose at bedtime  Indications: depression, including that associated with BPD
Mirtazapine (Remeron) effects	drowsiness, abnormal dreams, dry mouth, constipation, increased appetite, and asthenia  Drug interactions: additive CNS depressant effects with alcohol and CYP inhibitors
Trazodone (Desyrel, Oleptro)	Selectively inhibit serotonin reuptake but minimally affect norepinephrine reuptake Minimal adverse effects on cardiovascular system Indications: depression, insomnia effects: strong sedative qualities; impaired cognitive function in older adults
Adverse Effects: Antipsychotic Drugs	Agranulocytosis and hemolytic anemia CNS effects Drowsiness Neuroleptic malignant syndrome (NMS) Extrapyramidal symptoms (EPS): pseudoparkinsonism- akathisia, acute dystonia-treated with benztropine and trihexyphenidyl Tardive dyskinesia
Tardive dyskinesia (TD) psychotic drugs	Involuntary contractions of oral and facial muscles Choreoathetosis (wavelike movements of extremities) Occurs with continuous long-term antipsychotic therapy  Valbenazine (Ingrezza) used to treat tardive dyskinesia in adults
Haloperidol (Haldol)	Indications: long-term treatment of psychosis Contraindications: hypersensitivity, Parkinson’s disease, and in patients taking large amounts of CNS depressants
Atypical Antipsychotics	Clozapine (Clozaril)  Risperidone (Risperdal)  Olanzapine (Zyprexa)  Quetiapine (Seroquel)  Ziprasidone (Geodon)  Aripiprazole (Abilify)  Paliperidone (Invega)  Iloperidone (Fanapt)
Aripiprazole (Abilify) Brexipiprazole (Rexulti)	Used for schizophrenia, bipolar disorder, major depressive disorder, agitation associated with autistic disorder Adverse effects: similar to other atypical antipsychotics
Clozapine (Clozaril)	Selectively blocks the dopaminergic receptors in the mesolimbic region of the brain Associated with minor or no EPS Adverse effects: blood dyscrasias Monitor WBC counts frequently throughout beginning of therapy
Risperidone (Risperdal)	Indication: schizophrenia, including negative symptoms Adverse effects: minimal EPS at therapeutic dosages of 1 to 6 mg/day Risperdal Consta: long-acting injectable form; lasts approximately 2 weeks Invega Sustenna: long-acting injection
Tricyclics may need to be	weaned and discontinued before undergoing surgery to avoid interactions with anesthetic drugs
Antipsychotics—phenothiazines implications	Instruct patients to wear sunscreen because of photosensitivity. Tell patients to avoid taking antacids or antidiarrheal preparations within 1 hour of a dose. Inform patients to avoid alcohol and other CNS depressants with these medications
Certain opioid drugs are used to treat opioid dependence.	Methadone • Goal: reduce the patient’s dosage gradually so that eventually the patient can live permanently drug free • Relapse rates are often high; the drug can be abused
OPIOIDS: ADVERSE EFFECTS	Diuresis • Miosis • Convulsions • Nausea, vomiting • Respiratory depress • Non-CNS: • Hypotension • Constipation • Urinary retention • Flushing • Urticaria/pruritus
OPIOID: DRUG WITHDRAWAL	Peak period: 1 to 3 days • Duration: 5 to 7 days • Signs • Drug seeking, mydriasis, diaphoresis, rhinorrhea, lacrimation, diarrhea, elevated blood pressure (BP), and pulse • Symptoms muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise
Naloxone is a	opioid antagonist used in opioid overdose.
Naltrexone	Works by blocking the opioid receptors so that the use of opioid drugs do not produce euphoria • Must be 1 week free from opioids to begin this therapy
METHAMPHETAMINE	Stronger effects than other amphetamines • Pill form • Powder form: snorted or injected • Crystallized form • Also known as “ice,” “crystal,” “glass,” “crystal meth” • Smokable • More powerful
METHYLENEDIOXYMETHAMPHETAMINE	Usually prepared in secret home laboratories • More calming effects than other amphetamine drugs • Usually taken by pill • “Raves”
COCAINE	From the leaves of the coca plant • Snorted or injected intravenously • Highly addictive—physical and psychologic dependence • Powdered form • Also called “dust,” “coke,” “snow,” “flake,” “blow,” “girl”
Flunitrazepam	Not legal in US • “Roofies” • Cause relaxed, drunken feeling • Used with alcohol to produce disinhibition and amnesia • “Date-Rape” drug
DEPRESSANTS: ADVERSE EFFECTS	Overexpression of their therapeutic effects • CNS: • Drowsiness, sedation, lack of coordination, dizziness, blurred vision, headaches, paradoxical reactions • GI: • Nausea, vomiting, constipation, dry mouth, abdominal cramping
Benzodiazepines: toxic	Fatality is unusual when taken alone. • When combined with alcohol or other drugs, combination can be lethal. • Withdrawal sx: seizures, delirium, rebound anxiety, myoclonus, myalgia, sleep disturbances • Reversal: flumazenil
ETHANOL: DRUG EFFECTS	CNS depression • Respiratory stimulation or depression • Vasodilation, producing warm, flushed skin • Increased sweating
EFFECTS OF CHRONIC ETHANOL INGESTION	Nutritional and vitamin deficiencies (especially B vitamins) • Wernicke’s encephalopathy • Korsakoff’s psychosis • Polyneuritis • Nicotinic acid deficiency encephalopathy • Seizures • Alcoholic hepatitis, progressing to cirrhosis
Fetal alcohol syndrome (FAS)	Craniofacial abnormalities • CNS dysfunction • Prenatal and postnatal growth retardation
ALCOHOL INTERACTIONS	Interacts with antibiotic metronidazole • Hepatotoxicity with acetaminophen • Increase bioavailability of blood thinner warfarin
ETHANOL WITHDRAWAL TREATMENT	Benzodiazepines are the treatment of choice • Diazepam (Valium), lorazepam (Ativan), or chlordiazepoxide (Korsakoff’s psychosis) • Dosage and frequency depend on severity • For severe withdrawal, monitoring in an intensive care unit is recommended.
TREATMENT FOR ALCOHOLISM	Disulfiram (Antabuse) • Acetaldehyde syndrome • Naltrexone • Acamprosate (Campral) • Newest treatment • Counseling • Individual • Alcoholics anonymous
NICOTINE	Many smoke to “calm nerves.” • Releases epinephrine, which creates physiologic stress rather than relaxation • Tolerance develops • Physical and psychologic dependency • Withdrawal symptoms occur if stopped
NICOTINE: WITHDRAWAL TREATMENT	Treatments provide nicotine without the carcinogens in tobacco. • Nicotine transdermal system (patch) • Nicotine polacrilex (gum) • Inhalers • Nasal spray
NICOTINE WITHDRAWAL TREATMENT (CONT.)	Bupropion (Zyban): may be prescribed to aid in smoking cessation • First nicotine-free prescription medicine to treat nicotine dependence • Varenicline (Chantix) • Stimulates nicotine receptors
Thyroid Gland	Secretes three hormones essential for proper regulation of metabolism  Thyroxine (T4)  Triiodothyronine (T3)  Calcitonin
the parathyroid gland	responsible for maintaining adequate levels of calcium in the extracellular fluid
Hypothyroidism: Deficiency in Thyroid Hormones	Primary: abnormality in the thyroid gland itself  Secondary: results when the pituitary gland is dysfunctional and does not secrete thyroid-stimulating hormone (TSH)  Tertiary: hypothalamus gland does not secrete thyrotropin-releasing hormone
Congenital hypothyroidism (Cretinism)	Hyposecretion of thyroid hormone during youth  Low metabolic rate, retarded growth and sexual development, possible mental retardation
Myxedema	Hyposecretion of thyroid hormone during adulthood  Decreased metabolic rate, loss of mental and physical stamina, weight gain, loss of hair, firm edema, yellow dullness of the skin
Goiter	Enlargement of the thyroid gland  Results from overstimulation by elevated levels of TSH  TSH is elevated because there is little or no thyroid hormone in circulation
Hypothyroidism symptoms	Thickened skin  Hair loss  Constipation  Lethargy  Anorexia
Hyperthyroidism	Fatigue  Palpitations  Nervousness  Heat intolerance
Treatment of Hyperthyroidism	Radioactive iodine (I131) works by destroying the thyroid gland  Surgery to remove all or part of the thyroid gland  Lifelong thyroid hormone replacement will be needed.
Treatment of Hyperthyroidism drugs	Antithyroid drugs: thioamide derivatives  Methimazole (Tapazole)  Propylthiouracil (PTU)  Radioactive iodine (iodine 131)  Potassium iodide
Thyroid Replacement Drugs	Levothyroxine (Synthroid, Levoxyl)  Synthetic thyroid hormone T4  Most standardized and most widely used  Liothyronine (Cytomel)  Synthetic thyroid hormone T3  Liotrix (Thyrolar)  Synthetic thyroid hormone T3 and T4 combined
Thyroid Replacement Drugs: Adverse Effects	Cardiac dysrhythmia is the most significant adverse effect.  May also cause:  Tachycardia, palpitations, angina, hypertension, insomnia, tremors, headache, anxiety, nausea, diarrhea, menstrual irregularities, weight loss, sweating, heat intolerance
Levothyroxine (Synthroid)	Most commonly prescribed synthetic thyroid hormone  Chemically pure …100% T4 (thyroxine)  Daily dose  Best at in the morning on an empty stomach  Morning dosing avoids potential sleep disturbances if taken later in the day
Antithyroid Drugs	Used to treat hyperthyroidism and to prevent the surge in thyroid hormones that occurs after surgical treatment or during radioactive iodine treatment for hyperthyroidism
Antithyroid Drugs: Adverse Effects	Liver and bone marrow toxicity is the most damaging or serious adverse effect.
Propylthiouracil (PTU)	Thioamide antithyroid  2 weeks of therapy may be necessary before symptoms improve.
During pregnancy, treatment for hypothyroidism	should continue.  Fetal growth may be retarded if maternal hypothyroidism is untreated during pregnancy.  Adjust dosage every 4 weeks to keep TSH at the lower end of the normal range
Thyroid Crisis (Thyroid Storm)	Exacerbation of hyperthyroidism and is potentially life threatening  Assess for precipitating causes  Stress  Infection
Types of Antidiabetic Drugs	Insulins • Oral hypoglycemic drugs • Both aim to produce normal blood glucose states • Some new injectable hypoglycemic drugs may be used in addition to insulin or antidiabetic drugs.
Insulins	Function as a substitute for the endogenous hormone • Effects are the same as normal endogenous insulin. • Restores the diabetic patient’s ability to: • Metabolize carbohydrates, fats, and proteins • Store glucose in the liver
Rapid-acting treatment for types 1 and 2 DM insulin	Most rapid onset of action (5 to 15 minutes) • Peak: 1 to 2 hours • Duration: 3 to 5 hours • Patient must eat a meal after injection. • Insulin lispro (Humalog) • Similar action to endogenous insulin • Insulin aspart (NovoLog) • Insulin glulisine
Afrezza	rapid acting insulin, Peak of 12 to 15 minutes • Short duration of action of 2 to 3 hours • Administered within 20 minutes before each meal • Must be given in conjunction with long-acting insulins or oral diabetic agents (for type 2 DM)
Afrezza effects	Side effects: hypoglycemia, cough, and throat pain • Contraindicated: smokers and those with chronic lung diseases • Black box warning regarding the risk of acute bronchospasms
Short-Acting Insulins	Regular insulin (Humulin R) • Routes of administration: IV bolus, IV infusion, intramuscular (IM), SQ • Onset (SQ route): 30 to 60 minutes • Peak (SQ route): 2.5 hours • Duration (SQ route): 6 to 10 hours
Intermediate-Acting Insulins	Insulin isophane suspension (also called NPH) • Cloudy appearance • Often combined with regular insulin
Insulin glargine (Lantus)	long acting, Clear, colorless solution • Constant level of insulin in the body • Usually dosed once daily • Can be dosed every 12 hours • Referred to as basal insulin
Insulin detemir (Levemir)	long acting insulin, Duration of action is dose dependent. • Lower doses require twice-daily dosing. • Higher doses may be given once daily
Oral Antidiabetic Drugs	Used for type 2 DM • Effective treatment involves several elements. • Careful monitoring of blood glucose levels • Therapy with one or more drugs • Treatment of associated comorbid conditions such as high cholesterol and high blood pressure
Oral Antidiabetic Drugs: Biguanide	Metformin (Glucophage) • First-line drug and is the most commonly used oral drug for the treatment of type 2 DM • Not used for type 1 DM
Biguanides (metformin) effects	gastrointestinal (GI) tract: abdominal bloating, nausea, cramping, diarrhea, feeling of fullness • May also cause metallic taste, reduced vitamin B12 levels • Lactic acidosis is rare but lethal if it occurs.
Oral Antidiabetic Drugs: Sulfonylureas	Second generation: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta) • Stimulate insulin secretion from the beta cells of the pancreas, thus increasing insulin levels • Beta cell function must be present.
Oral Antidiabetic Drugs: Sulfonylureas effects	hypoglycemia, hematologic effects, nausea, epigastric fullness, heartburn, many others
Oral Antidiabetic Drugs: Glinides	Repaglinide (Prandin), nateglinide (Starlix) • Indication: type 2 DM • Action similar to sulfonylureas • Increase insulin secretion from the pancreas
Glinides effects	headache, hypoglycemic effects, dizziness, weight gain, joint pain, upper respiratory infection, or flulike symptoms
Oral Antidiabetic Drugs: Thiazolidinediones (Glitazones)	• Pioglitazone (Actos) • Rosiglitazone (Avandia) • Only available through specialized manufacturer programs • Insulin-sensitizing drugs • Indication: type 2 DM • MOA: • Decrease insulin resistance • “Insulin sensitizing drugs
Oral Antidiabetic Drugs: Adverse Effects	Alpha-glucosidase inhibitors • Flatulence, diarrhea, abdominal pain • Do not cause hypoglycemia, hyperinsulinemia, or weight gain
Oral Antidiabetic Drugs: Alpha-Glucosidase Inhibitors	Acarbose (Precose), miglitol (Glyset) • Indication: type 2 DM • Contraindications • Adverse effects
Oral Antidiabetic Drugs: Dipeptidyl Peptidase-IV (DPP-IV) Inhibitors	Sitagliptin (Januvia) • Saxagliptin (Onglyza) • Linagliptin (Tradjenta) • Alogliptin (Nesina)
Oral Antidiabetic Drugs: Mechanism of Action, DPP-IV inhibitors	Delay breakdown of incretin hormones by inhibiting the enzyme DPP-IV. • Incretin hormones increase insulin synthesis and lower glucagon secretion. • Reduce fasting and postprandial glucose concentrations
Oral Antidiabetic Drugs: Mechanism of Action Biguanides	Decrease production of glucose by the liver • Decrease intestinal absorption of glucose • Increase uptake of glucose by tissues • Do not increase insulin secretion from the pancreas
Oral Antidiabetic Drugs: Mechanism of Action Alpha-glucosidase inhibitors	Reversibly inhibit the enzyme alpha glucosidase in the small intestine • Result in delayed absorption of glucose • Must be taken with meals to prevent excessive postprandial blood glucose elevations
Oral Antidiabetic Drugs: Adverse Effects DPP-IV inhibitors	Upper respiratory tract infection, headache, and diarrhea • Hypoglycemia can occur and is more common if used in conjunction with a sulfonylurea.
Oral Antidiabetic Drugs: Indications	Used alone or in combination with other drugs and/or diet and lifestyle changes to lower the blood glucose levels in patients with type 2 DM
Injectable Antidiabetic Drugs	Amylin agonist • Pramlintide (Symlin) • Incretin mimetics • Exenatide (Byetta) • Dulaglutide (Trulicity) • Liraglutide (Victoza) • Albiglutide (Tanzeum) • Lixisenatide (Adlyxin)
Injectable Antidiabetic Drugs: Mechanism of Action Amylin agonist	Mimics the natural hormone amylin • Slows gastric emptying • Suppresses glucagon secretion, reducing hepatic glucose output • Centrally modulates appetite and satiety • Used when other drugs have not achieved adequate glucose control
Injectable Antidiabetic Drugs: Mechanism of Action Incretin mimetic	Mimics the incretin hormones • Enhances glucose-driven insulin secretion from beta cells of the pancreas • Only used for type 2 DM • Exenatide: injection pen device
injectable Antidiabetic Drugs: Adverse Effects	Amylin agonist • Nausea, vomiting, anorexia, headache • Incretin mimetics • Nausea, vomiting, and diarrhea • Rare cases of hemorrhagic or necrotizing pancreatitis • Weight loss
Sodium Glucose Cotransporter (SGLT2) Inhibitors	Inhibition of SGLT2 leads to a decrease in blood glucose caused by an increase in renal glucose excretion. • SGLT2 inhibitors: new class of oral drugs for the treatment of type 2 DM • Canagliflozin (Invokana), dapagliflozin (Farxiga),
Sodium Glucose Cotransporter (SGLT2) Inhibitors action	work independently of insulin to prevent glucose reabsorption from the glomerular filtrate, resulting in a reduced renal threshold for glucose and glycosuria
Sodium Glucose Cotransporter (SGLT2) Inhibitors (Cont.)	Other effects: may increase insulin sensitivity and glucose uptake in the muscle cells and decrease gluconeogenesis • Results: improved glycemic control, weight loss, and a low risk of hypoglycemia
Hypoglycemia	Abnormally low blood glucose level (below 50 mg/dL) • Mild cases can be treated with diet—higher intake of protein and lower intake of carbohydrates—to prevent rebound postprandial hypoglycemia.
Hypoglycemia Symptoms	Early • Confusion, irritability, tremor, sweating • Late • Hypothermia, seizures • Coma and death will occur if not treated.
Glucose-Elevating Drugs	Oral forms of concentrated glucose • Buccal tablets, semisolid gel • 50% dextrose in water (D50W) • Glucagon
Nursing Implications insulin	When drawing up two types of insulin in one syringe, always withdraw the regular or rapid-acting insulin first. • Provide thorough patient education regarding self- administration of insulin injections, including timing of doses,
Nursing Implications Oral antidiabetic drugs	Always check blood glucose levels before giving • Usually given 30 minutes before meals • Alpha-glucosidase inhibitors are given with the first bite of each main meal. • Metformin is taken with meals to reduce GI effects.
Metformin will need to be discontinued if the	patient is to undergo studies with contrast dye because of possible renal effects; check with the prescriber.
If hypoglycemia occurs:	Administer oral form of glucose if the patient is conscious. • Give the patient glucose tablets or gel, corn syrup, honey, fruit juice, or nondiet soft drink or have the patient eat a small snack, such as crackers or a half sandwich.
Deliver	D50W or glucagon IV if the patient is unconscious.
Bactericidal	kill bacteria
Bacteriostatic:	inhibit growth of susceptible bacteria rather than killing them immediately; eventually leads to bacterial death
sulfonamides abx	One of the first groups of antibiotics  Often combined with another antibiotic
sulfonamides abx action	Bacteriostatic action  Prevent synthesis of folic acid required for synthesis of purines and nucleic acid  Do not affect human cells or certain bacteria; they can use preformed folic acid
sulfonamides abx indications	Effective against both gram-positive and gram- negative bacteria  Treatment of urinary tract infections (UTIs)
sulfonamides abx effects	Hemolytic and aplastic anemia, agranulocytosis, thrombocytopenia, Photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, epidermal necrolysisHepatotoxicity, convulsions, crystalluria, toxic nephrosis
beta lactum abx	Penicillins  Cephalosporins  Carbapenems  Monobactams
Natural penicillins	Penicillin G  Penicillin V
Penicillinase-resistant drugs	Nafcillin  Cloxacillin  Oxacillin  Dicloxacillin
beta lactamase inhibitors	Bind with beta-lactamase enzyme to prevent break down of penicillin molecule  Clavulanic acid (clavulanate)  Tazobactam  Sulbactam  Avibactam
penicillin action	Inside the cell, they bind to penicillin-binding protein.  Once bound, normal cell wall synthesis is disrupted.  Result: Bacteria cells die from cell lysis.  Penicillins do not kill other cells in the body.
cephalosporins	Semisynthetic antibiotics  Structurally and pharmacologically related to penicillins  Bactericidal action  Broad spectrum
cephalosporins first gen	Cefadroxil (Duricef, Ultracef)  Cephradine (Velosef)  Cefazolin (Ancef)  Cephalexin (Keflex), Used for surgical prophylaxis and for susceptible staphylococcal infections
cephalosporins second gen	Cefaclor (Ceclor)  Cefprozil (Cefzil)  Cefoxitin (Mefoxin)  Cefuroxime (Zinacef)  Cefotetan (Cefotan)
Cefoxitin (Mefoxin): IV and IM	Used prophylactically for abdominal or colorectal surgeries  Also kills anaerobes
Cefuroxime	Zinacef is parenteral form; Ceftin is PO.  Surgical prophylaxis  Does not kill anaerobes
cephalosporins third gen	Most potent group against gram-negative bacteria  Less active against gram-positive bacteria  Examples  Cefotaxime (Claforan)  Ceftazidime (Fortaz)  Cefdinir (Omnicef)  Ceftizoxime (Cefizox)  Ceftriaxone (Rocephin)
Ceftriaxone (Rocephin)	IV and IM, long half-life, once-a-day dosing  Elimination is primarily hepatic.  Easily passes meninges and diffused into cerebrospinal fluid to treat central nervous system infections.
Ceftazidime (Ceptaz, Fortaz, Tazidime)	IV and IM forms  Excellent gram-negative coverage  Used for difficult-to-treat organisms such as Pseudomonas spp.
Ceftolozane (Zerbaxa)	Contains beta-lactamase inhibitor  Enhances gram negative activity
Ceftaroline (Teflaro)	Broader spectrum of antibacterial activity  Effective against a wide variety of organisms  MRSA
cephalosporins effects	Mild diarrhea, abdominal cramps, rash, pruritus, redness, edema  Potential cross-sensitivity with penicillins if allergies exist
carbapenems	Reserved for complicated body cavity and connective tissue infections in acutely ill hospitalized patients  Must be infused over 60 minutes  May cause drug-induced seizure activity
Imipenem/cilastatin (Primaxin) carbapenems	Used for treatment of bone, joint, skin, and soft tissue infections; many other uses  Cilastatin inhibits an enzyme that breaks down imipenem.
monobactams	Aztreonam (Azactam)  Synthetic beta-lactam antibiotic  Primarily active against aerobic gram-negative bacteria (E. coli, Klebsiella spp., Pseudomonas spp.)  Bactericidal  Parenteral use only  Used for moderately severe systemic infections
macrolides	Erythromycin (E-mycin, E.E.S, others)  Azithromycin (Zithromax)  Clarithromycin (Biaxin)  Fidaxomicin (Dificid, Dificlir)
macrolides action	Prevent protein synthesis within bacterial cells  Considered bacteriostatic  Bacteria will eventually die  In high enough concentrations, may also be bactericidal
macrolides indications	Strep infections  Streptococcus pyogenes (group A beta-hemolytic streptococci)  Mild to moderate upper and lower respiratory tract infections  Haemophilus influenzae  Spirochetal infections  Syphilis and Lyme disease
macrolides effects	Nausea, vomiting, diarrhea, hepatotoxicity, flatulence, jaundice, anorexia  Azithromycin and clarithromycin: fewer GI adverse effects, longer duration of action, better efficacy, better tissue penetration
tetracyclines	Natural and semisynthetic  Obtained from cultures of Streptomyces  Bacteriostatic: inhibit bacterial growth  Inhibit protein synthesis
Dairy products, antacids, and iron salts reduce	oral absorption of tetracyclines.
tetracyclines Should not be used in	children younger than age 8 years or in pregnant or lactating women because tooth discoloration will occur if the drug binds to the calcium in the teeth
tetracyclines indications	Gram-negative and gram-positive organisms, protozoa, Mycoplasma spp., Rickettsia spp., Chlamydia, syphilis, Lyme disease, acne, others  Demeclocycline is also used to treat syndrome of inappropriate antidiuretic hormone (ADH)
tetracyclines effects	Strong affinity for calcium  Discoloration of permanent teeth and tooth enamel in fetuses and children or nursing infants if taken by the mother  May retard fetal skeletal development if taken during pregnancy
All oral antibiotics are absorbed better if taken with at least	6 to 8 oz water
Sulfonamides implications	Take with 2000 to 3000 mL of fluid/24 hour.  Assess red blood cell count before beginning therapy.  Take oral doses with food.
penicillin implications	Take oral doses with water (not juices) because acidic fluids may nullify the drug’s antibacterial action.  Monitor patients taking penicillin for an allergic reaction for at least 30 minutes after administration.
Tetracyclines implications	Avoid milk products, iron preparations, antacids, and other dairy products because of the chelation and drug- binding that occur.  Take all medications with 6 to 8 oz of fluid, preferably water.  Because of photosensitivity, avoid sunlight
ESBL	rganisms that produce ESBL are resistant to all beta- lactam antibiotics and aztreonam.  Can be treated only with carbapenems or sometimes quinolones
aminoglycosides	Natural and semisynthetic  Produced from Streptomyces spp.  Poor oral absorption; no oral forms (exception: neomycin)  Very potent antibiotics
aminoglycosides ex	Gentamicin  Neomycin (Neo-Fradin)  Tobramycin (TOBI)  Amikacin
aminoglycosides indications	kill gram-negative bacteria, such as Pseudomonas spp., Escherichia coli, Proteus spp., Klebsiella spp., Serratia spp. Often used in combination with other antibiotics synergistic eftcs., lung infections  Exception: neomycin, decont. gi tract bef surg.
aminoglycosides effects	Cause serious toxicities  Nephrotoxicity (renal damage)  Ototoxicity (auditory impairment and vestibular impairment [eighth cranial nerve])  Must monitor drug levels to prevent toxicities Ototoxicity and nephrotoxicity
quinolones	Also called fluoroquinolones  Excellent oral absorption  Absorption reduced by antacids  Effective against gram-negative organisms and some gram-positive organisms
quinolones meds	Ciprofloxacin (Cipro)  Norfloxacin (Noroxin)  Levofloxacin (Levaquin)  Moxifloxacin (Avelox)  Gemifloxacin (Factive)
quinolones action	Alter DNA of bacteria, causing death  Do not affect human DNA  Used to treat S. aureus, Serratia marcescens, and Mycobacterium fortuitum
quinolones indication	ram-negative bacteria such as Pseudomonas spp.  Complicated urinary tract, respiratory, bone and joint, GI, skin, and sexually transmitted infections  Anthrax (ciprofloxacin)
quinolones interactions	Dairy products  Enteral tube feedings  Probenecid  Nitrofurantoin  Oral anticoagulants
Clindamycin (Cleocin)	Used for chronic bone infections, genitourinary infections, intraabdominal infections, other serious infections  May cause pseudomembranous colitis (also known as antibiotic-associated colitis, Clostridium difficile
Daptomycin (Cubicin)	Only drug of the new class known as lipopeptides  Mechanism of action is not completely known.  Binds to gram-positive cells in a calcium-dependent process and disrupts the cell membrane potential treat complicated skin and soft tissue infections
Colistimethate (Coly-Mycin)	Polypeptide antibiotic that penetrates and disrupts the bacterial membrane of susceptible strains of gram- negative bacterial  Commonly referred to as colistin  Serious adverse effects
Dalbavancin (Dalvance)	Lipoglycopeptide  Similar to telavancin in that it is indicated for the treatment of skin and skin structure infections caused by susceptible gram-positive organisms  Effective against MRSA  Extremely long half-life
Dalbavancin (Dalvance) effects	nausea, diarrhea, and headache
Linezolid (Zyvox)	Used to treat vancomycin-resistant Enterococcus faecium (VREF, VRE), hospital-acquired, and skin structure infections, including those with MRSA  May cause hypotension, serotonin syndrome
Metronidazole (Flagyl)	Used for anaerobic organisms  Intraabdominal and gynecologic infections  Protozoal infections  Several drug interactions
Nitrofurantoin (Macrodantin)	Primarily used for UTIs (E. coli, S. aureus, Klebsiella spp., Enterobacter spp.)  Use carefully if renal function is impaired  Drug concentrates in the urine  May cause fatal hepatotoxicity
Quinupristin–dalfopristin (Synercid)	30:70 combination; works synergistically  Used for bacteremia and infections caused by VRE and for treatment of complicated skin and skin structure infections
telavancin	Lipoglycopeptide  Treatment of skin and skin structure infections and pneumonia from gram + organisms  Adverse effects: renal toxicity, infusion-related reactions, QT prolongation
Vancomycin (Vancocin)	Treatment of choice for MRSA and other gram-positive infections  Oral vancomycin is indicated for the treatment of antibiotic-induced colitis (C. difficile) and for the treatment of staphylococcal enterocolitis.ototoxicity and nephrotoxicity
Vancomycin (Vancocin) pt 2	Red man syndrome may occur  Flushing or itching of head, neck, face, upper trunk  Antihistamine may be ordered to reduce these effects.  Additive neuromuscular blocking effects in patients receiving neuromuscular blockers infused over 60 minutes
Mycotic Infections	Cutaneous  Subcutaneous  Superficial  Systemic • Can be life threatening • Usually occur in immunocompromised host
Candida albicans	May follow antibiotic therapy, antineoplastics, or immunosuppressants (corticosteroids)  May result in overgrowth and systemic infections  Growth in the mouth is called thrush or oral candidiasis.
Vaginal candidiasis	Yeast infection  Pregnancy, women with diabetes mellitus, women taking oral contraceptives
Flucytosine	Also known as 5-fluorocytosine (5-FC), (antimetabolite)  Taken up by fungal cells and interferes with DNA synthesis  Result: fungal cell death
Griseofulvin	Disrupts cell division  Result: inhibited fungal mitosis (cell division)  Older drug; newer drugs are more commonly used
Polyenes	amphotericin B and nystatin  Bind to sterols in cell membrane lining  Result: fungal cell death  Do not bind to human cell membranes or kill human cells
Echinocandins:	caspofungin, micafungin, and anidulafungin  Prevent the synthesis of glucans (essential components of fungal cell walls)  Result: fungal cell death
Antifungal Drugs: Contraindications	Most common: drug allergy, liver failure, kidney failure, and porphyria (for griseofulvin)  Itraconazole: contraindicated treatment of onychomycoses in patients with severe cardiac problems  Voriconazole can cause fetal harm
Amphotericin B: Adverse Effects	Cardiac dysrhythmias  Neurotoxicity; tinnitus; visual disturbances; hand or feet numbness, tingling, or pain; convulsions  Renal toxicity, potassium loss, hypomagnesemia  Pulmonary infiltrates
Fluconazole effects	Nausea, vomiting, diarrhea, stomach pain  Increased liver enzymes  Use with caution in patients with renal and liver dysfunction
Antifungal Drugs: Contraindications	Liver failure  Renal failure  Porphyria (griseofulvin)  Drug allergy
Amphotericin B implications	To reduce the severity of the infusion-related reactions, pretreatment with an antipyretic (acetaminophen), antihistamines, antiemetics, and corticosteroids may be given.
hepatitis b	ransmission of hepatitis B virus occurs through blood and body fluid exposure.  Transmission to infants  Hepatitis B vaccine  Antiviral drug therapy for hepatitis B: lamivudine, tenofovir, and telbivudine
hepatitis c	Transmission: infected blood and sexual contact  Alcoholic disease can lead to development of hepatitis C.  Treatment: interferon, ribavirin, simeprevir, and sofosbuvir
Amantadine (Symmetrel)	Narrow antiviral spectrum; active only against influenza A  Most recent guidelines do not recommend use for treatment or prevention of flu.  Central nervous system (CNS) effects: insomnia, nervousness, light-headedness, anorexia, nausea
Rimantadine (Flumadine)	Same spectrum of activity, mechanism of action, and indications as amantadine  Fewer CNS adverse effects  Causes GI upset
Acyclovir (Zovirax)	Synthetic nucleoside analogue  Used to suppress replication of HSV-1, HSV-2, VZV  Drug of choice for treatment of initial and recurrent episodes of these infections
Ganciclovir (Cytovene)	ynthetic nucleoside analogue  Used to treat infection with CMV  Oral, parenteral forms  CMV retinitis
Ganciclovir	Bone marrow toxicity
Foscarnet and cidofovir	Renal toxicity
Oseltamivir (Tamiflu) and zanamivir (Relenza)	Active against influenza types A and B  Reduce duration of illness  Oseltamivir: causes nausea and vomiting  Zanamivir: causes diarrhea, nausea, sinusitis
four stages hiv	Stage 1: asymptomatic infection  Stage 2: early, general symptoms of disease  Stage 3: moderate symptoms  Stage 4: severe symptoms
Aspirin	Shown to reduce cardiac death after myocardial infarction (MI) ● Should be administered at the first sign of MI ● If not given before arriving in the emergency department, aspirin is one of the first drugs given
NSAIDs: Adverse Effects	heartburn to severe GI bleeding • Acute renal failure • Noncardiogenic pulmonary edema • Increased risk of MI and stroke • Altered hemostasis • Hepatotoxicity • Skin eruption
NSAIDs: Black Box Warning	All NSAIDs (except aspirin) share a black box warning regarding an increased risk of adverse cardiovascular thrombotic events, including fatal MI and stroke
Aspirin: Reye’s Syndrome	Acute and potentially life-threatening condition involving progressive neurologic deficits that can lead to coma and may also involve liver damage • Triggered by viral illnesses such as influenza as well as by salicylate therapy
NSAIDs: Salicylate Toxicity	Cardiovascular: increased heart rate • Central nervous: tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, lassitude, drowsiness • GI: nausea, vomiting, diarrhea • Metabolic: sweating, thirst
Indomethacin (Indocin)	Analgesic, antiinflammatory, antirheumatic, and antipyretic properties • Uses: RA, OA, acute bursitis or tendonitis, ankylosing spondylitis, acute gouty arthritis, PDA, and treatment of preterm labor
anti gout drugs	Allopurinol (Zyloprim) • Febuxostat (Uloric) • Colchicine (Colcrys) • Probenecid (Benemid) • Lesinurad (Zurampic)
ANTACIDS	BASIC COMPOUNDS USED TO NEUTRALIZE STOMACH ACID • SALTS OF ALUMINUM, MAGNESIUM, CALCIUM,
CALCIUM ANTACIDS MAY LEAD TO THE DEVELOPMENT OF	KIDNEY STONES AND INCREASED GASTRIC ACID SECRETION. • ANTACIDS CONTAINING MAGNESIUM MUST BE AVOIDED IN PATIENTS WITH RENAL FAILURE. Pulse not palpable with Doppler
ANTACIDS: MECHANISM OF ACTION	DO NOT PREVENT THE OVERPRODUCTION OF ACID BUT INSTEAD HELP TO NEUTRALIZE ACID SECRETIONS • PROMOTE GASTRIC MUCOSAL DEFENSE MECHANISMS
ANTACIDS: ALUMINUM SALTS	HAVE CONSTIPATING EFFECTS • OFTEN USED WITH MAGNESIUM TO COUNTERACT CONSTIPATION • OFTEN RECOMMENDED FOR PATIENTS WITH RENAL DISEASE
ANTACIDS: MAGNESIUM SALTS	COMMONLY CAUSE DIARRHEA; USUALLY USED WITH OTHER DRUGS TO COUNTERACT THIS EFFECT • DANGEROUS WHEN USED WITH RENAL FAILURE; THE FAILING KIDNEY CANNOT EXCRETE EXTRA MAGNESIUM
ANTACIDS: CALCIUM SALTS	MANY FORMS BUT CARBONATE IS MOST COMMON • MAY CAUSE CONSTIPATION, KIDNEY STONES • ALSO NOT RECOMMENDED FOR PATIENTS WITH RENAL DISEASE
ANTACIDS: SODIUM BICARBONATE	HIGHLY SOLUBLE • BUFFERS THE ACIDIC PROPERTIES OF HCL • QUICK ONSET BUT SHORT DURATION • MAY CAUSE METABOLIC ALKALOSIS
ANTACIDS AND ANTIFLATULENTS	ANTIFLATULENTS: USED TO RELIEVE THE PAINFUL SYMPTOMS ASSOCIATED WITH GAS • SEVERAL DRUGS ARE USED TO BIND OR ALTER INTESTINAL GAS AND ARE OFTEN ADDED TO ANTACID COMBINATION
ANTACIDS: ADVERSE EFFECTS	OVERUSE: METABOLIC ALKALOSIS • ALUMINUM AND CALCIUM: CONSTIPATION • MAGNESIUM: DIARRHEA • CALCIUM: KIDNEY STONES, REBOUND HYPERACIDITY
HISTAMINE 2 (H2) RECEPTOR ANTAGONISTS	REDUCE ACID SECRETION • ALL AVAILABLE OTC IN LOWER DOSAGE FORMS • MOST POPULAR DRUGS FOR TREATMENT OF ACID-RELATED DISORDERS • CIMETIDINE (TAGAMET) • NIZATIDINE (AXID) • FAMOTIDINE (PEPCID)
H2 ANTAGONISTS: MECHANISM OF ACTION	COMPETITIVELY BLOCK THE H2 RECEPTOR OF ACID-PRODUCING PARIETAL CELLS • REDUCED HYDROGEN ION SECRETION FROM THE PARIETAL CELLS • INCREASE IN THE PH OF THE STOMACH
H2 ANTAGONISTS: DRUG EFFECT AND INDICATIONS	DRUG EFFECT • SUPPRESSED ACID SECRETION IN THE STOMACH • INDICATIONS • GASTROESOPHAGEAL REFLUX DISEASE (GERD) • PUD • EROSIVE ESOPHAGITIS
H2 ANTAGONISTS: ADVERSE EFFECTS	OVERALL, VERY FEW ADVERSE EFFECTS • CENTRAL NERVOUS SYSTEM ADVERSE EFFECTS IN ELDERLY PATIENTS INCLUDE CONFUSION AND DISORIENTATION. • CIMETIDINE MAY INDUCE IMPOTENCE AND GYNECOMASTIA.
PROTON PUMP INHIBITORS	THE PARIETAL CELLS RELEASE POSITIVE HYDROGEN IONS (PROTONS) DURING HCL PRODUCTION. • THIS PROCESS IS CALLED THE PROTON PUMP.LANSOPRAZOLE (PREVACID) • OMEPRAZOLE (PRILOSEC) • RABEPRAZOLE (ACIPHEX)
PROTON PUMP INHIBITORS: MECHANISM OF ACTION	IRREVERSIBLY BIND TO H+/K+ ATPASE ENZYME • THIS BOND PREVENTS THE MOVEMENT OF HYDROGEN IONS FROM THE PARIETAL CELL INTO THE STOMACH. • RESULTS IN ACHLORHYDRIA—ALL GASTRIC ACID SECRETION IS TEMPORARILY BLOCKED
PROTON PUMP INHIBITORS: INDICATIONS	GERD • EROSIVE ESOPHAGITIS • SHORT-TERM TREATMENT OF ACTIVE DUODENAL AND BENIGN GASTRIC ULCERS • ZOLLINGER-ELLISON SYNDROME • NONSTEROIDAL ANTIINFLAMMATORY DRUG (NSAID)
PROTON PUMP INHIBITORS: ADVERSE EFFECTS	POSSIBLE PREDISPOSITION TO GI TRACT INFECTIONS: CLOSTRIDIUM DIFFICILE • OSTEOPOROSIS AND RISK OF WRIST, HIP, AND SPINE FRACTURES IN LONG-TERM USERS • PNEUMONIA • DEPLETION OF MAGNESIUM
PROTON PUMP INHIBITORS: DRUG INTERACTIONS	INCREASE SERUM LEVELS OF DIAZEPAM AND PHENYTOIN • WARFARIN: INCREASED CHANCE OF BLEEDING • ABSORPTION OF KETOCONAZOLE, AMPICILLIN, IRON SALTS, AND DIGOXIN
SUCRALFATE (CARAFATE)	CYTOPROTECTIVE DRUG • USED FOR STRESS ULCERS, PEPTIC ULCER DISEASE • ATTRACTED TO AND BINDS TO THE BASE OF ULCERS AND EROSIONS, FORMING A PROTECTIVE BARRIER OVER THESE AREAS
MISOPROSTOL (CYTOTEC)	PROSTAGLANDIN E ANALOGUE • PROSTAGLANDINS HAVE CYTOPROTECTIVE ACTIVITY. • PROTECT GASTRIC MUCOSA FROM INJURY BY ENHANCING LOCAL PRODUCTION OF MUCUS OR BICARBONATE, USED FOR PREVENTION OF NSAID-INDUCED GASTRIC ULCERS
SIMETHICONE	aNTIFLATULENT DRUG • USED TO REDUCE THE DISCOMFORTS OF GASTRIC OR INTESTINAL GAS (FLATULENCE) • ALTERS ELASTICITY OF MUCUS-COATED GAS BUBBLES, BREAKING THEM INTO SMALLER ONES
ANTIDIARRHEALS: MECHANISM OF ACTION	COAT THE WALLS OF THE GASTROINTESTINAL (GI) TRACT • BIND TO THE CAUSATIVE BACTERIA OR TOXIN, WHICH IS THEN ELIMINATED THROUGH THE STOOL • EXAMPLES: BISMUTH SUBSALICYLATE (PEPTO- BISMOL), ACTIVATED CHARCOAL, AND ANTILIPEMIC DRUGS
ANTIMOTILITY DRUGS: ANTICHOLINERGICS	DECREASE INTESTINAL MUSCLE TONE AND PERISTALSIS OF GI TRACT • RESULT: SLOWS THE MOVEMENT OF FECAL MATTER THROUGH THE GI TRACT • EXAMPLE: BELLADONNA ALKALOIDS
ANTIMOTILITY DRUGS: OPIATES	DECREASE BOWEL MOTILITY AND REDUCE PAIN BY RELIEF OF RECTAL SPASMS • DECREASE TRANSIT TIME THROUGH THE BOWEL, ALLOWING MORE TIME FOR WATER AND ELECTROLYTES TO BE ABSORBED • EXAMPLES: PAREGORIC, OPIUM TINCTURE, CODEINE
PROBIOTICS	ALSO KNOWN AS INTESTINAL FLORA MODIFIERS AND BACTERIAL REPLACEMENT DRUGS • BACTERIAL CULTURES OF LACTOBACILLUS ORGANISMS WORK BY: • SUPPLYING MISSING BACTERIA TO THE GI TRACT • SUPPRESSING THE GROWTH OF DIARRHEA-CAUSING BACTERIA
ANTIDIARRHEALS: INDICATIONS	ADSORBENTS: MILDER CASES • ANTICHOLINERGICS AND OPIATES: MORE SEVERE CASES • PROBIOTICS: ANTIBIOTIC-INDUCED DIARRHEA
ANTIDIARRHEALS: ADVERSE EFFECTS	ADSORBENTS • INCREASED BLEEDING TIME • CONSTIPATION, DARK STOOLS • CONFUSION • TINNITUS • METALLIC TASTE • BLUE TONGUE
DO NOT GIVE BISMUTH SUBSALICYLATE TO CHILDREN OR TEENAGERS WITH	CHICKENPOX OR INFLUENZA BECAUSE OF THE RISK OF REYE’S SYNDROME.
LAXATIVES: MECHANISM OF ACTION bulk forming	HIGH FIBER • ABSORB WATER TO INCREASE BULK • DISTEND BOWEL TO INITIATE REFLEX BOWEL ACTIVITY • EXAMPLES • PSYLLIUM (METAMUCIL) • METHYLCELLULOSE (CITRUCEL)
LAXATIVES: MECHANISM OF ACTION EMOLLIENT	STOOL SOFTENERS AND LUBRICANTS • PROMOTE MORE WATER AND FAT IN THE STOOLS • LUBRICATE THE FECAL MATERIAL AND INTESTINAL WALLS • EXAMPLES • STOOL SOFTENERS: DOCUSATE SALTS (COLACE, SURFAK) • LUBRICANTS: MINERAL OIL
LAXATIVES: MECHANISM OF ACTION HYPEROSMOTIC	NCREASE FECAL WATER CONTENT • RESULTS IN BOWEL DISTENTION, INCREASED PERISTALSIS, AND EVACUATION • EXAMPLES • POLYETHYLENE GLYCOL (PEG) • SORBITOL, GLYCERIN • LACTULOSE
LAXATIVES: MECHANISM OF ACTION saline	INCREASE OSMOTIC PRESSURE WITHIN THE INTESTINAL TRACT, CAUSING MORE WATER TO ENTER THE INTESTINES • RESULTS IN BOWEL DISTENTION, INCREASED PERISTALSIS, AND EVACUATION • EXAMPLES • MAGNESIUM HYDROXIDE (MILK OF MAGNESIA) • MAGNESIUM CITRATE
LAXATIVES: MECHANISM OF ACTION stimulant	INCREASES PERISTALSIS VIA INTESTINAL NERVE STIMULATION • EXAMPLES • SENNA (SENOKOT) • BISACODYL (DULCOLAX)
PERIPHERALLY ACTING OPIOID ANTAGONISTS	TREATMENT OF CONSTIPATION RELATED TO OPIOID USE AND BOWEL RESECTION THERAPY • BLOCK ENTRANCE OF OPIOID INTO BOWEL • STRICT REGULATIONS FOR USE
Bulk forming use	Acute and chronic constipation, irritable bowel syndrome, diverticulosis
Emollient use	Acute and chronic constipation, fecal impaction, facilitation of bowel movements in anorectal conditions
Hyperosmotic use	Chronic constipation, diagnostic and surgical preps
saline use	Constipation, diagnostic and surgical preps
stimulant use	Acute constipation, diagnostic and surgical preps
LAXATIVES: ADVERSE EFFECTS bulk	IMPACTION • FLUID OVERLOAD • ELECTROLYTE IMBALANCES • ESOPHAGEAL BLOCKAGE
LAXATIVES: ADVERSE EFFECTS Emollient	SKIN RASHES • DECREASED ABSORPTION OF VITAMINS • ELECTROLYTE IMBALANCES • LIPID PNEUMONIA
SEROTONIN BLOCKERS	BLOCK SEROTONIN RECEPTORS IN THE GI TRACT, CTZ, AND VCCTZ, AND VC •• USED FOR NAUSEA AND VOMITING IN PATIENTSUSED FOR NAUSEA AND VOMITING IN PATIENTS RECEIVING CHEMOTHERAPY AND FORRECEIVING CHEMOTHERAPY AND POSTOP NAUSEA AND VOMITING POSTOP NAUSEA
TETRAHYDROCANNABINOIDS	MAJOR PSYCHOACTIVE SUBSTANCE IN MARIJUANAMARIJUANA •• INHIBITORY EFFECTS ON RETICULAR FORMATION,INHIBITORY EFFECTS ON RETICULAR FORMATION, THALAMUS, CEREBRAL CORTEXTHALAMUS, CEREBRAL CORTEX
TETRAHYDROCANNABINOIDS pt 2	DRONABINOL (MARINOL) •• USED FOR NAUSEA AND VOMITING ASSOCIATEDUSED FOR NAUSEA AND VOMITING ASSOCIATED WITH CHEMOTHERAPY AND FOR ANOREXIAWITH CHEMOTHERAPY AND FOR ANOREXIA ASSOCIATED WITH WEIGHT LOSS IN AIDS
PHOSPHORATED CARBOHYDRATE SOLUTION	MINT-FLAVORED ORAL SOLUTION •• USED OFF LABEL FOR TREATMENT OF MORNINGUSED OFF LABEL FOR TREATMENT OF MORNING SICKNESS
HERBAL PRODUCTS: GINGER	FOR N/V.INCLUDING THAT CAUSED BY CHEMOTHERAPY, MORNING SICKNESS, AND MOTION SICKNESS ADVERSE EFFECTS • ANOREXIA, NAUSEA AND VOMITING, SKIN NAUSEA AND VOMITING, SKIN REACTIONS
Water-Soluble Vitamins	B-complex group and vitamin C Can be dissolved in water Easily excreted in the urine Cannot be stored by the body in large amounts
Fat-Soluble Vitamins	Vitamins A, D, E, and K Stored in the liver and fatty tissues Deficiencies occur only after prolonged deprivation from an adequate supply or from disorders that prevent their absorption.
Vitamin A	Fat soluble  Vitamin A (retinol) food sources: liver, fish, dairy products, egg yolks, dark green leafy vegetables, and yellow-orange vegetables and fruits  Vitamin A comes from carotenes, which are found in plants
Vitamin A: Functions	Required for growth and development of bones and teeth (morphogenesis) Essential for night and normal vision (rhodopsin) Necessary for other processes: Reproduction Integrity of mucosal and epithelial surfaces Cholesterol and steroid synthesis
Vitamin A: Indications	Dietary supplement Infants and pregnant and nursing women Deficiency states Hyperkeratosis of the skin Night blindness Other conditions Skin conditions
Vitamin A: Toxicity	ngestion of excessive amounts causes toxicity: Irritability, drowsiness, vertigo, delirium, vomiting, other symptoms Increased intracranial pressure in infants Generalized peeling of the skin
Vitamin D	Fat soluble “Sunshine vitamin” Responsible for proper utilization of calcium and phosphorus Vitamin D2 (ergocalciferol) Plant vitamin D Obtained through dietary sources
Vitamin D2–containing foods	Fish liver oils, saltwater fish Fortified foods: milk, orange juice, cereals Animal livers, eggs, butter, dairy products
Vitamin D: Functions	Works with parathyroid hormone to regulate absorption of and use of calcium and phosphorus Necessary for normal calcification of bone and teeth
Vitamin D: Indications	Dietary supplement Treatment of vitamin D deficiency Treatment and correction of conditions related to long-term deficiency: rickets, tetany, osteomalacia Prevention of osteoporosis
Vitamin D: Toxicity	Long-term ingestion of excessive amounts causes toxicity: Hypertension, weakness, fatigue, headache Anorexia, dry mouth, metallic taste, nausea, vomiting, abdominal cramps Ataxia and bone pain
Vitamin E	Fat soluble Four forms: alpha, beta, gamma, and delta tocopherol Dietary plant sources Fruits, grains, fortified cereals, vegetable oils, wheat germ, nuts Animal sources Eggs, chicken, meats, fish
Vitamin E: Functions	The exact biologic function of vitamin E is unknown. Believed to act as an antioxidant Unproved theory that vitamin E has beneficial effects for patients with cancer, heart disease, premenstrual syndrome, and sexual dysfunction
Vitamin E: Adverse Effects	Gastrointestinal (GI) tract Central nervous system (CNS) effects
Vitamin E: Toxicity and Management of Overdose	Toxicity is primarily limited to use in the newborn. Hemolysis of red blood cells (RBCs) can occur. Infants with low levels of glucose-6-phosphate dehydrogenase. Blood products may be indicated.
Vitamin K	Fat soluble  Three types: phytonadione (vitamin K1), menaquinone (vitamin K2), and menadione (vitamin K3)  Body does not store large amounts of vitamin K.  Vitamin K2 is synthesized by the intestinal flora
Vitamin K: Functions	Essential for synthesis of blood coagulation factors in the liver Vitamin K–dependent clotting factors
Vitamin K: Indications	Dietary supplementation  Treatment of deficiency states (rare)  Antibiotic therapy  Malabsorption  Given prophylactically to newborn infants  Reverses the effects of certain anticoagulants
Vitamin B1 (Thiamine)	Water soluble Food sources Enriched whole grain breads and cereals, liver, beans, yeast Deficiencies Beriberi Wernicke’s encephalopathy
Vitamin B1 (Thiamine): Deficiencies	Beriberi Brain lesions, polyneuropathy of peripheral nerves, serous effusions, cardiac anatomic changes Wernicke’s encephalopathy Also known as Cerebral beriberi
Vitamin B1 (Thiamine): Causes of Deficiencies	Poor diet Extended fever Hyperthyroidism Liver disease Alcoholism Malabsorption
Vitamin B1 (Thiamine): Functions	Essential for: Carbohydrate metabolism Many metabolic pathways, including Krebs cycle Maintains integrity of: Peripheral nervous system Cardiovascular system
Vitamin B2 (Riboflavin)	Water soluble Food sources Green, leafy vegetables Eggs, dairy products Nuts, legumes Meats, liver
Vitamin B2 (Riboflavin): Causes of Deficiency	Alcoholism is a major cause. Deficiency also caused by: Intestinal malabsorption Long-term infections Liver disease
Vitamin B2 (Riboflavin): Functions	Converted into enzymes essential for tissue respiration Required to activate vitamin B6 (pyridoxine) Converts tryptophan into niacin Maintains erythrocyte integrity
Vitamin B2 (Riboflavin): Deficiency	Deficiency results in: Cutaneous, oral, and corneal changes Cheilosis (chapped or fissured lips) Seborrheic dermatitis Keratitis
Vitamin B2 (Riboflavin): Indications	Dietary supplement Treatment of deficiency Microcytic anemia Acne Migraine headaches
Vitamin B3 (Niacin)	Water soluble Food sources Beans, turkey, tuna, liver, yeast Enriched whole-grain breads and cereals, wheat germ
Vitamin B3 (Niacin): Functions	Nicotinamide is converted to two coenzymes. These enzymes are required for: Glycogenolysis, tissue respiration Lipid, protein, and purine metabolism
Vitamin B3 (Niacin): Indications	Prevention and treatment of pellagra  Antihyperlipidemic drug  Lowers serum cholesterol and triglyceride levels by reducing very–low-density lipoprotein synthesis
Vitamin B3 (Niacin): Deficiency	Pellagra: niacin deficiency Mental: various psychotic symptoms Neurologic: neurasthenic syndrome Cutaneous: crusting, erythema
Vitamin B3 (Niacin): Adverse Effects	Flushing Pruritus GI distress
Vitamin B6 (Pyridoxine)	Water soluble Sources Whole grains, wheat germ, yeast Fish, organ meats, poultry, meats, eggs Peanuts, nuts, vegetables, bananas
Vitamin B6 (Pyridoxine): Function	Protein, lipid, and carbohydrate utilization Conversion of tryptophan to niacin Necessary for integrity of peripheral nerves, skin, mucous membranes, hematopoietic system
Vitamin B6 (Pyridoxine): Deficiency	Sideroblastic anemia Neurologic disturbances Seborrheic dermatitis Cheilosis (chapped, fissured lips) Glossitis, stomatitis Epileptiform convulsions
Vitamin B6 (Pyridoxine): Causes of Deficiency	Inadequate intake Poor absorption Uremia, alcoholism, cirrhosis, hyperthyroidism, malabsorption, heart failure
Vitamin B6 (Pyridoxine): Indications	Prevent and treat vitamin B6 deficiency. Seizures that are unresponsive to usual therapy Morning sickness during pregnancy
Vitamin B12 (Cyanocobalamin)	Water soluble Synthesized by microorganisms present in the body Food sources Liver, kidney, fish, shellfish, poultry, milk Eggs, blue cheese, fortified cereals
Vitamin B12 (Cyanocobalamin): Function	Required for many metabolic pathways Fat and carbohydrate metabolism Protein synthesis Growth, cell replication Hematopoiesis
Vitamin B12 (Cyanocobalamin): Deficiency	The most common manifestation of untreated cyanocobalamin deficiency is pernicious anemia. Deficiency leads to: Neurologic damage Megaloblastic anemia
Vitamin B12 (Cyanocobalamin): Oral Absorption	Oral absorption of vitamin B12 (extrinsic factor) requires presence of the intrinsic factor. The intrinsic factor is a glycoprotein secreted from the gastric parietal cells.
Vitamin C (Ascorbic Acid)	Water soluble Natural sources Citrus fruits and juices, strawberries Tomatoes, potatoes Broccoli, spinach, brussels sprouts Cabbage, green peppers
Vitamin C (Ascorbic Acid): Functions	Acts in oxidation-reduction reactions Required for several metabolic activities Collagen synthesis Maintenance of connective tissue Tissue repair Maintenance of bone, teeth, and capillaries
Vitamin C (Ascorbic Acid): Deficiency	Prolonged deficiency results in scurvy. Gingivitis and bleeding gums Loss of teeth Anemia Subcutaneous hemorrhage Bone lesions
Vitamin C (Ascorbic Acid): Indications	Dietary supplement Prevention and treatment of scurvy Urinary acidifier
Vitamin C (Ascorbic Acid): Megadoses	Megadoses may cause: Nausea, vomiting, headache, abdominal cramps Acidified urine, with possible stone formation Discontinuing megadoses may result in scurvy- like symptoms.
Calcium	Most abundant mineral element in the body Accounts for 2% of body weight Highest concentration in bones and teeth Efficient absorption requires adequate amounts of vitamin D.
Calcium Deficiency	Infantile rickets Adult osteomalacia Osteoporosis
Calcium: Toxicity	Anorexia Nausea Vomiting Constipation Severe hypercalcemia can cause: Cardiac irregularities Delirium
Calcium: Drug Interactions	Chelation Calcium salts will bind (chelate) with tetracyclines to produce an insoluble complex. If hypercalcemia is present in patients taking digoxin, serious cardiac dysrhythmias can occur.
Magnesium	One of the principal cations of intracellular fluid Essential for enzyme systems associated with energy metabolism Required for: Nerve physiology Muscle contraction
Magnesium: Adverse Effects	Tendon reflex loss Difficult bowel movements CNS depression Respiratory distress Heart block Hypothermia
Phosphorus foods	Milk Yogurt Cheese Peas Meat Fish eggs
Phosphorus Deficiency	Malabsorption Extensive diarrhea or vomiting Hyperthyroidism Long-term use of aluminum or calcium antacids Hepatic disease
Phosphorus: Functions	Required precursor for the synthesis of essential body chemicals Building block for body structures Required for the synthesis of: Nucleic acid Adenosine diphosphate Adenosine monophosphate
Phosphorus: Adverse Effects	Diarrhea Nausea and vomiting Other GI disturbances Confusion Weakness Breathing difficulties
Zinc	Trace element Essential in metabolic reactions of proteins and carbohydrates Important for normal tissue growth and repair, especially wound repair
Epoetin alfa (Epogen)	Biosynthetic form of the natural hormone erythropoietin  Used for treatment of anemia associated with end-stage renal disease, chemotherapy-induced anemia, and anemia associated with zidovudine therapy
Some foods enhance iron absorption	Orange juice  Veal  Fish  Ascorbic acid
Some foods impair iron absorption:	Eggs*  Corn  Beans*  Cereal products containing phytates
Iron Toxicity	Suction and maintenance of the airway; correction of acidosis; control of shock and dehydration with IV fluids or blood, oxygen, and vasopressors In patients with severe symptoms of iron intoxication, such as coma, shock
iron overload	Deferiprone
Ferrous Fumarate (Femiron)	Contains largest amount of iron per gram of salt consumed 33% elemental iron Oral use only
Ferrous Sulfate	Most frequently used oral iron 300 mg BID or TID for adults Each tablet contains 65 mg of elemental iron.
Parenteral Iron	Iron dextran (INFeD, Dexferrum) May cause anaphylactic reactions, including major orthostatic hypotension and fatal anaphylaxis A test dose of 25 mg of iron dextran is administered before injection of the full dose
Ferric gluconate (Ferrlecit)	Indicated for repletion of total body iron content in patients with iron-deficiency anemia who are undergoing hemodialysis Risk of anaphylaxis is much less than with iron dextran
Injectable Iron: Iron Sucrose	Venofer  Indicated for anemic patients with chronic renal failure  Less risk for precipitating anaphylaxis than with iron dextran  No test dose required  Adverse effects: hypotension
Folic Acid (Folate)	Water-soluble, B-complex vitamin Essential for erythropoiesis Primary uses Folic acid deficiency During pregnancy to prevent neural tube defects

Created by: cwehner125

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