1
Q
efficacy, safety, cost, and patient adherence are factors associated with what?
A
Drug selection
2
Q
When prescribing, what must be followed?
A
Evidence-based clinical guidelines
3
Q
medication purpose, how and when to take medication, time to expected effect, common vs. serious adverse effects, when to contact provider, and avoidance of abrupt discontinuation are key components of what?
A
General pharmacologic patient education
4
Q
What are the phases of FDA drug approval process?
A
- Preclinical: Animal studies assessing toxicity
- Phase I: Safety and PK in healthy volunteers
- Phase II: Efficacy and ADRs in affected patients
- Phase III: Large-scale comparison trials
- Phase IV: Post-marketing surveillance
5
Q
Who regulates approval and labeling of drugs?
A
FDA
6
Q
Who regulates NP scope and prescriptive authority?
A
State Board
7
Q
Who regulates controlled substances?
A
DEA
8
Q
What is required for a NP to be able to prescribe controlled medications?
A
DEA number
9
Q
What scehdule drug is marijuana currently at the federal level?
A
Schedule I
10
Q
Federally, is there accepted medical prescribing of marijuana?
A
no
11
Q
What type of drugs activate receptors and produces the same effect as the endogenous molecule?
A
Agonists
12
Q
What type of drugs mimic the effects of endogenous molecules but do not produce the full effect.
A
Partial agonists
13
Q
Describe ED50
A
It is the dose that produces therapeutic response in 50% of a group. AKA “standard” or “average” dose.
14
Q
Explain LD50
A
This is the dose of drug that is lethal in 50% of a group. It is determined in preclinical trials.
15
Q
How is theraputic index calculated?
A
LD50/ED50
16
Q
Why is it important to know if a drug has a narrow therapeutic index?
A
Patients taking these drugs require closer monitoring to ensure dose is therapeutic.
17
Q
What is the relationship between warfarin and protein?
A
Warfarin is highly protein bound. Only free drug is active and displacement can increase bleeding risk.
18
Q
How are generic equivalents verified?
A
FDA Orange Book
19
Q
What are some factors that affect absorption?
A
Route of administration, GI environment, blood flow, and food/drug interactions.
20
Q
What term describes the ability of a drug to ilicit a physiologic response when it interacts with a receptor?
A
Efficacy
21
Q
What term describes the amount of drug needed to produce a certain response?
A
Potency
22
Q
Heat/ice, PT, TENS, massage, and cognitive techniques are all forms of what?
A
Non-pharm pain management
23
Q
What central analgesic has hepatotoxic risk and should be used carefully in patients with chronic alcohol use or liver disease?
A
Acetaminophen
24
Q
Which medication class inhibits COX, decreasing prostaglandins. These drugs can cause GI bleeding, renal impairment, and CV risk.
A
NSAIDS
25
If a patient with history of GI bleed is taking ibuprofen, what would be a reasonable alternative to suggest?
A COX 2-inhibitor like celebrex
26
What type of drugs are used to treat acute migraine attacks by causing vasoconstriction?
Triptans and ergotamine
27
What side effects should we monitor for in a patient taking a thiazide?
Hypokalemia, hyperglycemia
28
What medications do NSAIDS interact with?
Anticoagulants and hypertensives
29
What is a major adverse reaction of celebrex?
Increased CV risk
30
What is methylnaltrexone (MTNX) used for?
Treatment of opioid-induced contipation
31
What medication is used for latent TB prevention?
INH
32
What is important patient education when using metronidazole?
Do not consume alcohol (disulfiram like reaction)
33
A pregnant woman is having migraines. Is ergotamine a safe prescription?
No. Ergotamine is a known teratogenic med.
34
what type of medications prevent conversion of angiotensin I to angiontensin II, resulting in decreasing vasoconstriction, angiotensin II levels, and aldosterone secretion which causes vasodilation, decrease in BP, decrease in Na and water retention, and reduced cardiac workload?
ACE Inhibitors
35
which type of medication lowers BP, decreases Na and water retention, and vasodilates by blocking angiotensin II from binding to angiontensin II (AT1) receptors?
ARBs
36
Both ACEis and ARBs can cause hypotension, hyperkalemia, renal impairment, and are contraindicated in pregnancy. What additional ADRs are specific to ACEis but not ARBs
Angioedema and cough
37
What are two factors that can increase risk for digoxin toxicity?
Hypokalemia and renal impairment
38
What medications, when taken with digoxin, increase risk for digoxin toxicity?
Macrolides, fluoroquinolones, GLP-1s, diuretics
39
What labs should be monitored when taking HCTZ?
Potassium (hypokalemia), sodium (hyponatremia), calcium (hypercalcemia)
40
What medication is used for treatment of heart failure with reduced EF and is intended to replace ACEi or ARB if appropriate? This med cannot be used with an ACEi and requires a 36 hour "wash-out" period after stopping an ACEi
Entresto
41
How is warfarin dosing determined?
Based on INR. Target INR 2.0-3.0
42
If a patient taking warfarin also takes a macrolide, fluoroquinolone, cepahlosporin, or zosyn what is the associated risk?
Increased INR --> Increased bleeding risk
43
What is the antidote for warfarin?
Vitamin K
44
What is the antidote for heparin?
Protamine sulfate
45
What is the blackbox warning for Vorapaxar?
Intracranial hemorrhage
46
What are bile acid sequestrants like welchol and colestipol used for? Why are they different than most other lipid lowering agents?
Used to treat hyperlipidemia. Not contraindicated in patients with active liver disease
47
What labs are required before starting a patient on a statin?
LFTs
48
What are some ADRs of statins?
Myalgia, myopathy, rhabdo
49
Is gemfibrozil an effective LDL lowering drug?
No. It is most effective at lowering triglycerides
50
What is important to not when talking about effectiveness of guafenesin?
There is limited research proving its efficacy. Efficacy is heavily dependant on adequate hydration
51
A patient taking theophylline begins complaining of N/V/D and abdominal pain. What should you suspect?
Early signs of theophylline toxicity
52
A patient taking theophylline who had previously reported N/V/D and abdominal pain now presents with seizures. What is supected?
Severe theophylline toxicity
53
What asthma medication has a black box warning for neuropsychiatric events such as agitation, depression, sleep disturbances, suicidal ideation, and behavioral changes?
Montelukast (Singulair)
54
What oral decongestant should be used cautiously or avoided in patients with hypertension, CAD, arrythmias, hyperthyroidism, BPH, and diabetes?
Pseudophedrine
55
List 2 rescue inhalers named in the slides
- Albuterol (ProAir, Proventil, Ventolin)
- Levalbuterol (Xopenex)
56
What medications stimulate beta 2 recpetors in bronchial smooth muscle, increase cAMP adenylate cyclase activation, and cause smooth muscle relaxation leading to bronchodilation?
Beta 2 agonists
57
What is the theraputic range for theophylline?
10-20 mcg/mL
58
What are important notes about cromolyn?
Not to be used as rescue medication. Requires regular use. Less affective than ICS.
59
What are important cuations/contraindications related to avandia?
- Increased risk of heart failure
- Can worsen existing heart failure
- Causes fluid retention and edema
- Contraindicated in patients with heart failure
60
Are lispro (humalog), aspart (Novolog), glulisine (Apidra), Humulin R, Novolin R, glargine (Lantus), detemir (Levemir), and degludec (Tresiba) clear or cloudy?
Clear
61
Which insulins are cloudy?
NPH
- Humulin N
- Novolin N
62
What ADRs are associated with sulfonlyureas?
- Hypoglycemia
- Weight gain
- SIADH
- Disulfiram like reaction when taken with alcohol
63
What are common SGLT2 side effects?
- UTIs
- Yeast infections
- Fournier's gangrene (rare but critical)
64
Before prescribing a biguanide like metformin, what baseline labs should be obtained?
- Creatinine
- GFR
- LFTs
65
In what scenarios may glucagon be less effective?
Patients who are malnourished, use alcohol chronically, have liver disease, and have a current prolonged fast.
66
In relation to insulin requirements, how may infection, physiologic stress, pregnancy, and corticosteroid use change amount of insulin needed
These factors may result in need for increased insulin requirements
67
What is repaglinide (Prandin) most effective at treating? What can limit its effectiveness?
- Most effective at lowering postprandial BG
- Effectiveness lost if meals are missed
- Requires multiple daily doses
68
What are some important notes about methimazole
- Adherence is critical for efficacy
- Do not stop abruptly
- Take at the same time each day
- Notify provider if you have fever, sore throat (agranulocytosis)
69
What is a serious complication of overtreatment ith synthroid?
Osteoporosis
70
What is important to kno about synthroid and levothyroxine equivalency?
They are pharmacologically equivalent but brand and generic formulations are not considered interchangable. It is recommended to stay with the same brand/manufacturer because slight variations can cause drastic hormonal effects
71
What is the relationship between thyroid hormones and pregnancy. What is recommended?
Thyroid hormone requirements increase during pregnancy. Levothyroxine in pregnancy is safe and recommended.
72
What are ADRs of antacids?
- Magnesium based: Diarrhea, hypermagnesemia
- Aluminum based: Constipation, hypophosphatemia
- Calcium based: Constipation, hypercalcemia, milk-alkali syndrome
- Sodium bicarbonate: Metabloic acidosis
73
What are important ADRs related to PPIs?
- Vitamin B12 deficiency
- hypomagnesemia
- Decreased calcium absorption (increased fracture risk)
74
What are carafate administration guidelines?
- Take on empty stomach
- Administer 1 hours before meals
- Take separately from all other meds
- Take other meds at least 2 hours before or after carafate
75
What cardiac side effects are related to zofran?
- Long QT syndrome
- Torsades de pointes
76
What is MOA of reglan?
It blocks dopamine which associates it with TD and extrapyramidal symptoms
77
What is an important age guideline related to tetracyclines?
Tetracycline administration is contraindicated in children younger than 8 years old
78
What is included in the black box warning for fluoroquinolones?
- Tendinitis, tendon rupture (main one)
- Peripheral neuropathy
- CNS effects
- AAA and dissection
79
What is a notable point regarding Emverm administration?
Dose will be repeated in 2 weeks to kill newly hatched worms.
80
What is the CDC recommendation for prevention of TB?
- Treatment of latent TB with INH
81
What do tetracyclines, fluoroquinolones (cipro, levofloxacin), and sulfonamides (bactrim) all have in common... Besides being antibiotics
They are photosensitive
82
What are important diet teaching points for a patient taking monoamine oxidase inhibitors?
Avoid tyramine-containing foods (aged cheese, cured or smoked meats, fermented foods, soy sauce, draft beer, red wine
83
What is an important food to avoid when taking carbamazepine?
Grapefruit, alcohol
84
What are the 2 major ADRs related to lamotrigine (Lamictal)
- SJS
- Toxic epidermal necrosis (TEN)
85
What psych meds can cause weight gain?
- Atypical 2nd gen antipsychotics (zyprexa, clozapine)
- Mood stabilizers (Depakote, lithium)
- Antidepressants (mirtazapine, SSRIs)
86
What is the relationship between lithium and sodium?
- The kidneys handle sodium and lithium similarly.
- If sodium decreases, lithium is retained, increasing serum concentration.
- This is why hydration is crucial when taking lithium.
- Dehydration = lithium toxicity
87
What are early, moderate, and severe signs of lithium toxicity?
- Early/mild: N/V/D, fine tremor, thirst, polyuria
- Moderate: Coarse tremor, ataxia, slurred speech, muscle weakness, confusion
- Severe: Seizures, severe confusion/delirium, dysrhytmias, coma, hypotension
88
What is the therapeutic level of lithium?
- Approx. 0.6 to 1.2 mEq/L
- Toxicity = >1.5 mEq/L
- Severe toxicity = > 2.0 mEq/L
89
What psych meds have risk for prolonged QT?
- Thioridazine
- Ziprasidone (Geodon)
- TCAS
- Celexa
90
What are clinical classical features of neuroleptic malignant syndrome?
- High, sustained fever
- Autonomic instability (Tachycardia, labile BP, diaphoresis, dysrhythmias)
- "Lead pipe" muscle rigidity, genralized stiffness
- Mental status changes
- Elevated CK
- Symptoms start within days or weeks of starting treatment or after dose increase
91
What are common/important ADRs of antipsychotic medications?
- Extrapyramidal Symptoms (acute dystonia, akathisia, parkinsonism, tardive dyskinesia
- Metabolic symptoms (weight gain, hyperglycemia, dyslipidemia, metabolic syndrome)
- Severe: Neuroleptic malignant syndrome, seizures
92
What are identifying factors of serotonin syndrome?
- Mental status changes
- Autonomic instability (hyperthermia, diaphoresis, tachycardia, hypertension)
- Neuromuscular abnormalities
93
What are important tricyclic antidepressant ADRs?
- Anticholinergic effects
- Highly cardiotoxic in overdose
- Seizures (lowers seizure threshold)
94
What are important blackbox warnings and age guidelines for antidepressants?
- Increased risk for suicide
- High risk in patients 24 and younger
95
What are some ADRs related to bupropion?
- Seizures (most important)
- Weight loss
- CNS stimulant effects
96
What are first-line classes of medications for depression and anxiety?
- SSRIs (Zoloft, Prozac, Lexapro, Celexa, Paxil)
- SNRIs (Effexor, Cymbalta, Pristiq)
97
What medications listed in the powerpoints should not be stopped abruptly?
- Beta blockers
- SSRIs and SNRIs
- Benzos
- Corticosteroids
- Antiepileptics and mood stabilizers
- Clonidine
- Lithium
- PPIs
DNP
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